PBM 101: Past & Present

Traditional PBM is murky. AmeriClear Rx is crystal clear.

A Brief History

Pharmacy Benefits Management (PBM) began in the late 1970s to help manage the claims process for plan sponsors and insurance carriers. PBMs met a huge need as pharmacy benefits became more common. By 1990, the majority of pharmacy claims were administered electronically by PBMs for a small fee per claim.

The PBM companies began to morph into profit giants in the early 1990s. Initially some innovation in the PBM model was a cost-containment tool. The creation of formularies and multiple copay tiers influenced drug spend by driving members, prescribers, and pharmacies to lower-cost therapies. But ultimately, with the influx of drug-manufacturer revenue, this process became a huge revenue stream that often was not in the best interest of the plan sponsor or the member.

A Flawed, Complicated System

Claims and pricing manipulation ballooned. A two-contract model became the PBM standard, charging the plan sponsor based on one contract and paying the pharmacy based on another. The PBM kept the difference, or spread—as much as several hundred dollars per prescription in some cases!

Drug Code Repackaging is another way PBMs gain spread. Different Maximum Allowable Costs (MAC) on generics pricing lists and inconsistencies in updating prices favor higher profits for the PBM and higher costs for the plan sponsors.

The PBM industry began to consolidate into large entities, and PBM-owned mail order and specialty pharmacy facilities were derived to create other streams of revenue. The priority was to maximize the PBM mail order prescription business many times at the expense of the employer or plan sponsor.

The result today is an intensely consolidated market that operates a complex, costly system while touting imaginary savings for the plan sponsor.

You can read more about mail order waste here…

An Easy, Equitable Solution

When something is broken, it makes sense to fix it. So that’s what we did. AmeriClear Rx is how a PBM should operate. It’s a win-win-win for employers, brokers and pharmacists.

We are founded by pharmacists, which means we understand the critical value of a one-contract model. We’ve streamlined the purchasing process and pride ourselves on a battalion of happy, headache-free customers.

We don’t own or promote mail order. We believe members are best served by having the freedom to choose their pharmacy.

Finally, a PBM that gets it. Connect with AmeriClear Rx TODAY.