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Understanding the Role of the PBM

priorauthtraining.org · 2,289 words · saved by 1 readers

When a patient visits their primary care physician, they are prescribed medications by their physician, in which they will send over to the patient’s preferred pharmacy. When the pharmacy receives the prescription for the patient, they’ll verify that the drug is on formulary, covered by the patient’s health insurance and submit a claim. The insurance company would review the claim and verify the patient’s coverage to check deductibles, copayments, and coinsurance. The insurance would determine the reimbursement amount based on the patient’s plan which factors in deductible and copayment. The patient may have to pay a portion of the medication cost if the insurance doesn’t cover the whole amount. The pharmacy would also be reimbursed by the insurance company for the medication dispensed based on the cost of the medication and the patient’s payment.1 Pharmacy benefit managers (PBMs) play a part in each of these steps. PBMs, or pharmacy benefit managers, are third-party administrators tha

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