Facts Patients Should Know about

Pharmacy Benefit Managers (PBMs)

·        Groups such as employers, insurance companies and unions contract with PBMs to manage prescription drug programs. These groups will be referred to as "Clients".

·    PBMs provide prescription drug cards, which are used at the local pharmacy to fill prescriptions.

·    PBMs guide their clients in establishing co-pays for drugs.

·    PBMs contract and negotiate with drug manufacturers to have their drugs included in the preferred drug list.  This process is why drugs are switched from preferred to non-preferred status, and patients must change drugs to keep their lower co-pay.

·    PBMs own mail order pharmacies, which they coerce patients to use rather than the local pharmacy.  As the number of patients who use mail order increases, the PBMs make a larger profit, and the amount the client pays for a prescription drug program increases.

How Does the Client, PBM, Pharmacy and

 Patient Fit Together?

·        Groups such as employers, insurance companies and unions (clients) contract with PBMs to manage prescription drug programs. 

·    PBMs provide those covered individuals with prescription drug cards.

·    When a covered individual has a prescription filled at the local pharmacy, he/she presents the prescription drug card to the pharmacist.

·    The pharmacist fills the prescription and charges the patient the co-pay established for that drug.

·    The pharmacist bills the PBM for the cost of the prescription.

·    The PBM reimburses the pharmacist for the cost of the prescription.

·    The PBM then charges the group (example: employer, insurance company or union) an amount including the administrative fees and the pharmacist’s reimbursement.