What is a Pharmacy Benefit Manager?
A Pharmacy Benefit Manager, also known as a PBM, administers prescription drug plans for those who have health insurance from a variety of sponsors including commercial health plans, self-insured employer plans, union plans, Medicare Part D plans, the
Federal Employees Health Benefits Program (FEHBP), state government employee plans, managed Medicaid plans, and others. PBM’s are designed to specifically save employers and members pharmacy costs.
What is a prescription drug list?
A prescription drug formulary is a drug list used by doctors and other health care providers. It is a list of "covered" prescription medicines developed by doctors and pharmacists working for a health care organization or pharmacy benefits manager (PBM).
Prescription drug lists are used to control costs while still providing quality medication.
What is a covered drug?
Covered medications are medications that are covered or paid for by your health insurance. The prescription drug list contains a listing of the covered medications. You can use the Prescription Drug formulary to verify that your prescription is for a
covered medication.
How are drugs selected for the prescription drug list?
Prescription drugs are reviewed for safety, effectiveness and value. Cost is just one factor in putting a drug on or taking a drug off the prescription drug list when other similar medications are available.
Why has there been a price change for my Pharmacy benefits and prescription?
Each Pharmacy Benefit Manager (PBM) has a different formulary that is contracted with different rates. This results in various drugs/prescriptions costing changes from PBM to PBM. In some cases, you may pay more for a drug and in other cases you may pay
less. This again all depends on the drug and the contracted rates with the PBM.
Some factors of price increases and decreases are:
- Contracted prices vary from PBM to PBM
- Manufacturer ingredients cost may fluctuate
- When changing from PBM to PBM drug Co-pay Tiers may change (ex. Tier 2 drug may now be Tier 3 etc.)
- Prices may not always go up, you may see a price decrease
- Speak with your pharmacy staff to advise you of co-pay assistance programs that may be available.
What is Prior Authorization?
A prior Authorization, also referred to as a P.A, is a requirement that is needed for any medical prescription or drug you were on with your previous insurance carrier.
A Prior Authorization is needed so that we can review the medication(s) and make sure it is medically necessary and appropriate for the medical situation.
What types of Drugs need Prior Authorization?
- Drugs that have dangerous side effects
- Drugs that are often misused or abused
- Drugs that you should use only for certain Health Conditions
- Drugs that are harmful when combined with other drugs
- Drugs that a Doctor prescribes when less expensive drugs may work better
What is a Specialty Drug?
If you have a chronic or difficult health condition, you may need a specialty drug. Conditions like Multiple sclerosis and Rheumatoid Arthritis are examples of conditions where Specialty drugs may be needed.
A Specialty Drug typically requires special handling, administration or monitoring. It is also more likely they’ll need special approval to order, and you may have to order them through a specialty pharmacy.
How do I know if my medication is a Specialty Drug?
To find out if your drug is a Specialty Drug, simply visit your Pharmacy Benefit Manager’s Formulary website and type in the name of your drug. There, you can look up the specific drug(s) and see what it is categorized and if any further action
is needed, for example if the drug needs a Prior Authorization, has a quantity limit, requires Step Therapy, Age Limits etc.
What is a Step Therapy?
Step Therapy is an approach designed to control costs and potential health risks associated with prescription drugs.
You may also hear Step Therapy referred to as Step Protocol or a Fail First Requirement.
When you are diagnosed with a medical condition, your Physician will start you out with the most cost effective drug therapy. As needed, you will progress to other more costly or risky therapies only if necessary
What is an example of Step Therapy?
Step Therapy helps let us know that less expensive options do not work before your plan will cover the drug. Below is an example of step therapy:
- You try an over-the-counter medication for your medical condition, but it doesn’t control your symptoms
- Your doctor then prescribes a prescription drug that still doesn’t give you any relief
- A third medication that's more expensive works well but requires step therapy
- Your prescription will be covered if you've tried the first-choice drugs. If you haven't tried step therapy, the drug may cost you more, or may not be covered at all.