Understanding Pharmacy Benefit Managers (P.B.M.s)

Introduction to Pharmacy Benefit Managers (P.B.M.s)

If you’ve ever faced challenges in obtaining a prescription drug, you’ve likely encountered a pharmacy benefit manager (P.B.M.). These companies, operating behind the scenes, have a significant impact on the availability of drugs and the costs you bear. Acting as intermediaries in the intricate American healthcare system, P.B.M.s work on behalf of employers and government insurance programs, such as Medicare, which cover a significant portion of prescription drug expenses.

Role of Pharmacy Benefit Managers

The primary responsibility of P.B.M.s is to reduce costs related to medications. However, an investigation by The New York Times revealed that the major P.B.M.s often lead to increased out-of-pocket expenses for consumers.

Identifying Your Pharmacy Benefit Manager

Most individuals in the United States are affiliated with one of the three prominent P.B.M.s—CVS Caremark, Express Scripts, or Optum Rx. Even if you are associated with a smaller P.B.M. like Prime Therapeutics, the practices of these major players can still impact you as smaller P.B.M.s often outsource some of their operations to the larger firms.

This distinction is crucial as your P.B.M. arrangement differs from selecting a health insurance plan during an annual open enrollment period. Your P.B.M. is typically determined for you, unlike the flexibility of choosing a health plan.