PBMs & Their Role in the Pharmaceutical Industry

<p>All of the above. (D)</p> Signup and view all the answers

<p>All of the above. (D)</p> Signup and view all the answers

<p>PBMs are raising concerns about their influence on the market, prompting calls for increased regulation. (C)</p> Signup and view all the answers

<p>PBM's are a necessary tool for obtaining WC medications. (C)</p> Signup and view all the answers

<p>PBM's can delay medication filling due to the need for approvals. (C)</p> Signup and view all the answers

<p>PBM's can help reduce costs associated with prescription drugs for injured workers. (B)</p> Signup and view all the answers

<p>PBM's may not always guarantee the filling of a prescription, despite offering a prescription card. (D)</p> Signup and view all the answers

<p>PBM's can make it more difficult for injured workers to access their medications. (C)</p> Signup and view all the answers

<p>The medication is deemed unnecessary or inappropriate for the patient's condition. (B)</p> Signup and view all the answers

<p>PBMs are a tool used by insurance carriers to control costs associated with prescription drugs. (C)</p> Signup and view all the answers

<p>A lack of transparency in the prescription filling process for patients. (A)</p> Signup and view all the answers

<p>PBMs may become too powerful and influence policy decisions. (A)</p> Signup and view all the answers

<p>All of the Above (@)</p> Signup and view all the answers

<p>To process prescription claims and manage drug formularies. (A)</p> Signup and view all the answers

<p>By expanding into mail-order and specialty pharmacy services. (C)</p> Signup and view all the answers

<p>All of the above (E)</p> Signup and view all the answers

<p>Reduced access to comprehensive healthcare for certain patient groups. (B)</p> Signup and view all the answers

<p>To control drug costs by limiting access to certain medications and promoting generics. (E)</p> Signup and view all the answers

<p>It makes it difficult for patients to understand and appeal coverage denials for medications. (A)</p> Signup and view all the answers

<p>The role of PBMs has evolved from simply processing claims to a more comprehensive healthcare management. (A)</p> Signup and view all the answers

<p>It can potentially create a monopoly in the healthcare industry. (C)</p> Signup and view all the answers

<p>All of the above. (D)</p> Signup and view all the answers

PBMs cover approximately 270 million Americans, managing prescription drugs.

CVS Health controls 33%, Cigna 24%, UnitedHealth 22%, others less.

Only about 50% of workers' compensation medications are authorized immediately by PBMs.

PBMs owned by drug manufacturers raise antitrust concerns due to potential conflicts of interest.

PBMs receive rebates from manufacturers that aren't disclosed to clients, possibly not sharing savings.

PBMs may favor more expensive drugs in their formularies due to manufacturer's financial influence.

PBMs may switch prescribed medications to generics or alternatives without consulting the doctor.

PBMs use practices that harm small independent pharmacies, impacting competition.

Since 2006, drug prices have risen 313% partly due to PBM practices.

PBMs began gaining significant market presence in the 1980s with electronic claims processing.

In 2011, Maine repealed a law mandating fiduciary disclosure by PBMs.

As of 2022, six PBMs accounted for 96% of the market share in prescription management.

2011 saw the founding of OptumRx by UnitedHealth Group as part of PBM growth.

PBMs manage prescription drug costs and improve access for injured workers.

Patients often believe they must use PBMs for obtaining WC medications.

PBMs often offer a 'first fill' program to help injured workers obtain medications quickly.

PBMs conduct reviews for high-cost prescriptions, potentially reducing overall spending.

Insurance carriers see PBMs as a means to manage medication costs and reduce spending.

PBMs can complicate patient care and lead to worse clinical outcomes due to bureaucracy.

PBMs help decrease the time adjusters spend on claimant medication issues.

The benefits of PBMs, like prescription cards, can be revoked and do not guarantee medication fills.

PBMs earn revenue through spread pricing and rebates from pharmaceutical companies.

PBMs may hurt patient care due to their cumbersome processes, affecting outcomes.

An organization that manages prescription drug benefits for health plans.

A group of pharmacies working under agreement with a PBM to provide discounted medications.

A service run by PBMs that delivers prescriptions through the mail directly to patients.

Pharmacies that focus on high-cost, often injectable medications, managed by PBMs.

Lists of medications approved for coverage that PBMs use to manage costs and access.

Issues related to competition that arise when PBMs merge with insurance companies.

The system through which PBMs negotiate discounts and rebates from drug manufacturers.

Limits defined by PBMs that trigger denial or non-approval for certain medications.

Complex procedures used by PBMs to manage drug authorizations and approvals.

The flow of patients directed to contracted pharmacies by PBMs.