Benefit management, pharmacy services provided

Many third parties hire pharmacy benefit managers (PBMs) to provide prescription claims processing and other services. Examples of third parties that hire PBMs are insurance companies, employers, Medicare prescription drug plans, and state Medicaid programs. PBMs establish pharmacy networks as part of their claims management services, so many pharmacy third-party contracts are with PBMs. Examples of other ser-... 

Based upon how these healthcare delivery and financial management strategies are designed and implemented, MCOs are classified into different types or models - HMOs, PPOs, point-of-service (POS) plans and integrated service networks. In addition, pharmacy benefit management organizations provide specialized services to managed care. 

Pharmacy benefit managers (PBMs) are business entities that provide processes and services related to the acquisition and utilization of drugs by customers. They are the technical and clinical conduits for benefit payers (e.g., employers, employer groups, government) to develop, administer, and maintain a pharmacy benefit on behalf of the patients receiving the benefits. 

Another pharmacy benefits management service is the creation and management of pharmacy networks. These networks consist of outpatient pharmacies under contract to MCOs and/or their contractual PBM partners to provide drug services, typically at a negotiated, discounted fee. PBMs have reported that drug cost savings for their clients have been achieved, in part, by use of discounted fees for pharmacies in their networks [3,8]. 

Pharmacists also can benefit from building professional relationships with a core network of physicians who can refer patients to the pharmacy for adherence-related services. Reimbursement for cognitive services or disease state management programs is often tied to provider referrals. Providers usually make referrals to other specialists based on trust and their expertise and professional competence. A physician is more likely to refer a patient to a pharmacy when they have confidence in the content of the services and the competence of the pharmacist administering the therapeutic plan. Accountability (i.e., having the name of an individual, rather than an organization, responsible for the services rendered) is also important. 

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