Pharmacy Benefit Managers (PBMs) are companies that manage prescription drug benefits on behalf of health insurance companies, government plans, and other payors. They negotiate drug prices with pharmaceutical manufacturers and pharmacies, process claims, and determine which drugs are covered by insurance plans. While PBMs were initially created to help reduce healthcare costs by controlling drug spending, they have become a major source of frustration for pharmacies.
One of the ways PBMs can hinder pharmacies is through their reimbursement rates. PBMs often set low reimbursement rates for pharmacies, which can make it difficult for them to cover their costs and still make a profit. This can be especially challenging for independent pharmacies, which may not have the same bargaining power as larger chains. Let QRx show you how no matter the size of the pharmacy, we provide additional insight on the reimbursement pieces that determine poor reimbursement vs increased revenue.
Another way PBMs can hinder pharmacies is through their restrictive network contracts. PBMs often require pharmacies to sign contracts that limit their ability to work with other PBMs or negotiate better reimbursement rates. This can make it difficult for pharmacies to compete with larger chains and can limit their ability to provide the best possible care to their patients.
PBMs can also hinder pharmacies by creating administrative burdens. PBMs often require pharmacies to submit claims electronically, which can be costly if the pharmacy has to resubmit several times. They may also require pharmacies to obtain prior authorization for certain drugs, which can be a complex and time-consuming process. Determining if a claim will need a PA after the initial fill can be accomplished with QRx’s Post reporting edit. This allows the pharmacy to be proactive in initiating the PA process to ensure drug coverage before the next refill is due.
In addition to these challenges, PBMs have also been criticized for their lack of transparency. PBMs often operate in a black box, making it difficult for pharmacies to understand how they determine reimbursement rates or which drugs are covered by insurance plans. This lack of transparency can make it difficult for pharmacies to plan and make informed decisions about their business. QRx can shine a light on where the PBMs fail to provide the necessary details to ensure proper reimbursement, compliance, and additional AWP resubmission opportunities.
In conclusion, PBMs can hinder pharmacies in a variety of ways, from setting low reimbursement rates to creating administrative burdens and limiting their ability to compete. While PBMs were initially created to help reduce healthcare costs, it is important to ensure that they are not hindering the ability of pharmacies to provide the best possible care to their patients. Let QRx be the extra set of eyes for your pharmacy and give your business a piece of mind.
