Top 5 Pharmacy Benefits Managers (PBMs) and How They Work

Pharmacists taking inventory in pharmacy
Caiaimage/Rafal Rodzoch / Getty Images

In the pharmaceutical and healthcare industries, there is a unique vocabulary, particularly when it comes to job titles. Understanding how different roles work together is essential for your success.

What Is a Pharmacy Benefit Manager?

A pharmacy benefit manager, also known as a PBM, is an organization that provides services, educational programs, and services to aid patients. They do this through affecting the behaviors of pharmacists and doctors to prescribe drugs appropriately to maximize their effectiveness.

PBMs are intermediaries between through insurers and other aspects of the healthcare industry. Because of their size, they can negotiate large customer contracts and negotiate with both pharmacies and pharmaceutical companies to get the best rates.

Members of the pharmacy profession should know which PBMs dominate the market, very large companies have the greatest leverage to negotiate reimbursement rates for medications and patient care services.

Responsibilities of PBMs

It can be helpful to think of PBMs as a middleman in the healthcare process. It can take a good deal of planning and logistical work to get the medications you need to you on time. In the regard, PBMs have a great deal of responsibility, including:

  • Negotiating rebates to get the most affordable options
  • Operate mail order, so medications are delivered directly to the patients' doors
  • Over patient compliance to ensure the medication is taken as prescribed
  • Process claims from patients and pharmacies
  • Manage formularies, so individuals know what medications are covered through their health plans
  • Manage distribution among a network of pharmacies
  • Provide specialty services, such as connecting pharmacists or individuals to orphan drug supplier or biologic manufacturers

    As you can see, PBMs have a myriad of responsibilities that facilitate your care.

    Five Biggest PBMs

    The five biggest PBMs operating in the United States are very large, covering more than 50 percent of patients with pharmacy benefits. The following are the five largest PBMs in the country, in terms of funding and growth:

    1. ExpressScripts: ExpressScripts provides novel solutions for navigating pharmacy costs and improving patient care. Since ExpressScripts is not owned by or linked to any pharmaceutical company, their focus is entirely on its customers. Its focus on pharmacy benefits results in better patient care. 
    2. CVS Caremark: CVS Caremark is a growing PBM, providing comprehensive drug benefit services to over 2,000 healthcare plan sponsors and participants throughout the United States. 
    3. Argus: Argus is one of the last independent providers of healthcare information and services supporting Medicaid and Medicare Part D, serving some of the country's most vulnerable populations. They have a wide range of clients, from managed care organizations to pharmaceutical manufacturers.  
    4. Envision: Envision prides itself on its transparency to the public and its full disclosure on costs, agreements, and negotiations. Recently, Envision was acquired by Walgreens, so some change is expected moving forward. 
    1. ProCare RX: ProCare RX is national pharmacy benefit manager with decades of experience in healthcare information technology. 

    The healthcare system is very complex, with many companies involved that go far beyond the doctor and pharmacist relationship. PBMs play a pivotal role in getting you the drugs you need at a price you can afford and use their vast resources to negotiate on behalf of insurers and customers.