Navigating PBM Contracting and Implementation: A Comprehensive Guide
Pharmacy Benefit Managers (PBMs) play a critical role in managing prescription drug benefits for health plans and employers. They negotiate with drug manufacturers and pharmacies to ensure beneficiaries receive access to affordable, high-quality medications. In this blog, we will discuss the importance of PBM contracting and implementation and some key considerations when working with PBMs. So keep reading!
When contracting with a PBM, it is essential to consider the following:
- Scope of Services: The contract should clearly outline the services the PBM will provide, including formulary management, drug utilization management, network management, and claims processing.
- Pricing: The contract should specify the pricing structure and how costs will be allocated among the plan sponsor, members, and PBM.
- Performance Guarantees: The PBM Consulting and contracting should include performance guarantees related to service levels, accuracy, and quality of care.
- Contract Length: The contract should have a reasonable term length that allows for flexibility in case of changes in the market or plan needs.
Once a contract is in place, the PBM will begin implementing services. The following are some key considerations during the implementation process:
- Data Integration: The PBM should work with the plan sponsor to ensure data is accurately and securely transferred between systems.
- Network Adequacy: The PBM must ensure that the pharmacy network is adequate to provide members with medication access.
- Member Communications: The PBM should inform members about the new benefits and any changes to their prescription drug coverage.
- Provider Education: The PBM should educate providers about the new benefits and how to access information related to the pharmacy benefit.
- Performance Monitoring: The PBM should monitor performance regularly to ensure that services are delivered as agreed upon in the contract.
PBM contracting and implementation are critical processes that can significantly impact the quality and cost of prescription drug benefits for health plans and employers. By carefully considering the scope of services, pricing, performance guarantees, and contract length during the contracting process, plan sponsors can ensure that they are getting the most value from their partnership with a PBM.
Additionally, during implementation, plan sponsors should focus on data integration, network adequacy, member communications, provider education, and performance monitoring to ensure that services are being delivered as agreed upon in the contract. By following professional PBM Consulting, plan sponsors can improve the quality of care for their beneficiaries while managing costs and improving outcomes.