The Consolidated Appropriations Act (CAA) of 2021 expanded the Employee Retirement Income Security Act of 1974 (ERISA), which assigns fiduciary responsibility to self-insured employers for the healthcare services they purchase. Navigating the Maze: Employer Responsibilities in PBM Contracts Although the assignment of fiduciary responsibility is not new, the CAA recently expanded the scope of employer […]
read more
Pharmacy Benefit Managers (PBMs) make money through various revenue streams and business models. Here are the primary ways PBMs generate revenue: Pharmacy Benefit Managers: Revenue Game 1. Spread Pricing: Reimbursement Model: PBMs negotiate pricing contracts with pharmacies and payers, including health insurance plans and employers. Markup: PBMs reimburse pharmacies at one rate and charge the […]
read more
Group Purchasing Organizations (GPOs) play a significant role in the healthcare industry by leveraging the collective purchasing power of their members to negotiate discounted prices and favorable terms for medical supplies, pharmaceuticals, and other healthcare products and services. Group Purchasing Organization Relevance to a PBM While GPOs primarily focus on negotiating contracts for medical supplies […]
read more
Spread pricing is a practice commonly associated with pharmacy benefit managers (PBMs) in the healthcare industry. It refers to the difference between what a PBM charges a health plan sponsor (such as an employer or insurer) for pharmacy services and what the PBM reimburses pharmacies for dispensing medications to patients. Here’s how spread pricing typically […]
read more
