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Pharmacy Contracting & Reimbursement

July 19, 2016
PBMs contract with pharmacies on behalf of health plans and employers to serve patients by building networks of preferred pharmacies. As part of the negotiations to become a preferred network provider, pharmacies and PBMs negotiate contract types, payment rates for
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Drug Cost Management

July 19, 2016
The management of high cost drugs is receiving increased attention from patients, providers, payers, and policymakers due to ongoing drug price increases and the aggregate impact on health care costs. PBMs are responsible for creating novel solutions to improve the quality
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FEHB Program

July 19, 2016
The Federal Employees Health Benefits (FEHB) Program is the employer-sponsored federal group health insurance program that covers over 9 million federal civilian employees, retirees, former employees, and their families. The FEHB Program is voluntary and is financed through employee and
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TRICARE

July 19, 2016
TRICARE is the health care program for uniformed service members and their families around the world. This includes active duty and retired members of the: U.S. Army, U.S. Air Force, U.S. Navy, U.S. Marine Corps, U.S. Coast Guard, the Commissioned
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Medicaid

July 19, 2016
Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal
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Health Insurance Marketplace (ACA)

July 19, 2016
The Affordable Care Act (ACA) established new Health Insurance Marketplaces, through which individuals and small business can purchase health coverage. No matter which state an individual lives in, all Marketplace health plan options must offer patients ten standardized categories of benefits — referred to as Essential Health
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Medicare Part D

July 19, 2016
Created by the Medicare Modernization Act of 2003, Medicare Part D provides a prescription drug benefit to Medicare enrollees. The Part D benefit is administered by private stand-alone drug plans and Medicare Advantage drug plans. Over the last decade, market-based
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Employers, Unions, & Insurers

July 19, 2016
PBMs administer prescription drug plans for more than 266 million Americans with health coverage provided through Fortune 500 employers, health insurers, and labor unions, as well as through public programs such as Medicare and Medicaid. A common thread connecting all programs
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