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

Pharmacists work with a PBM
••• Caiaimage/Rafal Rodzoch / Getty Images

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.

The PBM is an intermediary between insurers and other members 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 PBM dominates the market. Very large companies have the greatest leverage to negotiate reimbursement rates for medications and patient care services.

Responsibilities of a PBM

© The Balance 2018

It can be helpful to think of a PBM 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 that regard, PBMs have a great deal of responsibility, including:

  • Negotiating rebates to get the most affordable options
  • Operating mail order, so medications are delivered directly to the patients' doors
  • Ensuring patient compliance in taking medication as prescribed
  • Processing claims from patients and pharmacies
  • Managing formularies, so individuals know what medications are covered through their health plans
  • Managing distribution among a network of pharmacies
  • Providing specialty services, such as connecting pharmacists or individuals to orphan drug suppliers or biologic manufacturers

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

Five Biggest PBM companies

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. 
  5. 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. The PBM plays a pivotal role in getting you the drugs you need at a price you can afford and in using their vast resources to negotiate on behalf of insurers and customers.