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Our experience managing pharmacy and medical benefits gives us a more powerful approach to achieve better quality pharmacy benefits at the lowest Alluma is shifting the focus back to patient care by creating a new entity that is uniquely aligned to the needs of its clients and their members. With a Pharmacy Benefits Illuminator, we negotiate on the same side of the table as our clients, helping them Since , Serve You Rx has been the pharmacy benefit manager PBM of choice for benefit and insurance brokers and consultants and their clients, including employers, unions, coalitions and governmental entities, as well as third party administrators TPAs WellDyneRx is a full-service, independent Pharmacy Benefit Manager PBM that makes the little things matter for our clients, employees, partners, and members.
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Pharmacy Benefit Managers PBMs are covered in this profile; scroll down for market access strategy presentations and articles plus a list of the largest PBMs The PBM sector is complex, competitive and continues to evolve. It's a diverse clinical and commercial environment of healthcare and pharmacy benefits, MCOs, commercial insurance carriers, clinical services, payers, consumers, employers, employee benefit consulting firms, prescribers nurse practitioners, doctors , retail, mail order and specialty pharmacies and other stakeholders.
The sector routinely attracts scrutiny from various regulatory agencies, political circles and consumer watchdog groups. PBMs negotiate with pharmaceutical manufacturers to minimize cost increases and assure adequate supply.
PBM clients including employer groups and managed care organizations rely on PBMs to deliver high-performance prescription benefit plan management in maximizing generic substitution and preferred brand drug prescribing by clinicians plus enforcement of other formulary or prescription drug plan guidelines and rules. PBMs are often called on to manage where prescription drugs are dispensed from.
Retail pharmacies are preferred for acute care, shorter duration prescriptions; mail order pharmacy is preferred for prescriptions taken for months at a time and referred to as "maintenance medications" such as blood pressure, cholesterol, oral contraceptives and other therapies.
These products play important roles in the treatment of rare diseases and conditions. They are frequently associated with what is referred to as "specialty pharmacy" therapies. While there are not many patients requiring these products, costs tend to run high for them as they are very specialized and required a great deal of research and development to be brought to market.
Another hurdle is since the patient count is low, there are fewer opportunities for pharmaceutical manufacturers to achieve ROI. PBMs are responsible for managing these and other high cost, high profile products to verify they are dispensed within the guidelines of pharmacy benefit plans and that patients on them receive appropriate support.
The distinct priority needs for the products is clear coupled with high treatment costs as a combined issue. PBMs are tasked with managing the benefit plans through which the products are covered -sometimes this entails channeling the prescription to be paid through the medical benefit if it can be obtained at a lower cost for patients and plan sponsors.
Prior authorizations and other utilization monitoring features or programs are part of the rigor for patients and clinicians as PBMs verify what the clinician is treating the patient for by prescribing a particular drug.
PBM Mergers and Acquisitions. Amazon Pharmacy and its PillPack unit represent a new wrinkle in mail order pharmacy and prescription benefit management competition that undoubtedly has big plans for CVS Health and Aetna. It will be a full-service prescription benefit manager and enable Anthem to maintain its own prescription drug formulary.
CVS Health will benefit through seeing more business in its specialty, mail order and retail pharmacy operations. It is important to remember CVS not only operates its CVS-branded retail pharmacies but also the retail pharmacies in Target stores as well. CVS is also likely to benefit through developing care programs to support Anthem members at its store-based MinuteClinics.
Anthem transitioned its business from Express Scripts now owned by Cigna by the end of It is a combination of specialty pharmacy and mail order pharmacy coupled with pharmacy benefit management services. The organization operates as its business unit with a dedicated management team; the IngenioRx and CVS partnership model has many parallels to this arrangement.
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