Pharmacy Benefit Manager (PBM) 2

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Pharmacy Benefit Manager (PBM):

Pharmacy Benefit Manager (PBM) Are you getting what you paid for?

PBM Pricing Strategies:

PBM Pricing Strategies This type of marketplace can often be a “buyers market”, but the complexities of PBM pricing strategies often work in the PBM’s favor. The correct contractual language is crucial to making sure that the cost benefit is in your favor. It’s all in the “fine print”. The following slides will ask some pointed questions to help you gauge whether or not a complete PBM contractual review is appropriate.

PBM Revenue Channels:

PBM Revenue Channels Network Spread This is the difference in what YOU pay for a prescription versus what the PBM reimburses the Pharmacy. Rebates and Manufacturer Administrative Fees From the Pharmaceutical Manufacturer. Retail Pharmacy This area is open to rules with regards to how you are charged and how discounts are calculated. Administrative Fees Fees based on claims processing (such as dispensing fees) and clinical programs.

Questions that you should ask:

Questions that you should ask Does your PBM contract have the following stipulations: Are you being invoiced based on real pass-through pricing? Are there generic guarantees that include every generic drug dispensed, not just a subset? Does your contract set forth exactly how penalties will be calculated if PBMs breach your generic guarantees? Do you know whether the PBM will pay out for all guarantees that are not met? 4. Do you know how the member’s payment is applied to charges? It may not always be your set benefit copayment.

Next Steps:

Next Steps The goal of significantly decreasing prescription drug costs – and increasing generic drug savings – is largely determined by the contractual terms. If you answered “NO” to any of the questions on the previous slide – or are unaware of the answer – you should consider a complete PBM contract review and full Request-For-Proposal (RFP) process.


Follow-Up If you have any questions, or would like to discuss in further detail, please contact Lisa Perry or Brian Lenzo. Lisa Perry Brian Lenzo Preferred Benefits Services 1.800.558.5658

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