Pharmacy Benefits Management (PBM) is a cloud-based, cost-effective management tool which can work virtually through web services. The tool facilitates processing of drug prescriptions, and this supports insurance companies in reducing their pharmacy claims costs all while effectively enhancing healthcare for their members.
A PBM solution is capable of generating reports periodically (daily, weekly, monthly or quarterly), monitoring turnaround times, and analyzing trends as well as identifying possible fraud, waste and abuse. Additionally, PBM solutions can perform patient safety audits, manufacturer rebate contracting, mail order pharmacy, chronic medication management schemes, and formulary management.
There are two rules associated with a PBM solution: payer rules and drug utilization review rules. Drug utilization review rules consist of drug-to-drug interaction, drug-disease, duplicate therapy, age, gender, and contraindication. On the other hand, payer rules include detecting over prescription, refill checks, real-time network member eligibility, real-time benefit eligibility, live aggregate limits, and benefit limits check.