Georgia GA Health Insurance Question
Reader’s Question:
I have a health insurance policy in Georgia that has a prescription drug benefits. What is a Pharmacy Benefits Manager? What does one do in relevance to my benefits?
Richard
Macon, GA
Hello there, Richard!
You see, I tried to search for answers to your question and I finally ran into one at a pharmacy. Well, apparently as its name implies, the Pharmacy Benefits Manager (PBM) will be the one who is contracted by your health insurance company to administer prescription benefits. You are not really getting drugs directly through your insurance plan, as what it might seem to you.
So what is the purpose of a Pharmacy Benefits Manager in your health insurance claims in Georgia? There is no other way I can simplify this explanation but this way: Pharmacy Benefits Manager (PBM) has the objective to provide health insurance plan members with access to a broad spectrum of necessary drugs, at the same time keep the costs to a minimum.
But how is this achieved? They are really the ones who negotiate with pharmacies in the background, at the same time develop the plan formulary. The plan formulary is the lost of drugs which are covered under the policyholder’s plan. If the medication is not included in the formulary, then it will not be covered by the health insurance policy. Aside from this, the PBM will also implement cost-containment measures such as requiring prior authorization or documentation from the policyholder’s doctor before a prescription can be filled.
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