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> pharmacy benefit managers The qualifications to become a pharmacy benefit manager include a bachelor's degree, at least five years of experience as a pharmac
by devoply 7y ago
> pharmacy benefit managers
The qualifications to become a pharmacy benefit manager include a bachelor's degree, at least five years of experience as a pharmacist, and five years in health plan pharmaceutical management.
So a bozo pharmacist can trump a doctor's judgment.
- lotsofpulp 7y agoA pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules.
- sjb554 7y agoHaha I was about to write this. Agree that a PBM is not an individual person.
- sorokod 7y ago>"They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules" Not how it is described in the article. Is the article incorrect in your opinion?
- lotsofpulp 7y agoI can't read the article, since it doesn't work on Safari with content blocker enabled, but it's pretty clear that a doctor is free to prescribe whatever they want. The patient is free to obtain the prescription also. The third party payer is also free to object to paying for something it believes should not be paid for under the agreement between the patient and the payer.
- sorokod 7y ago> a doctor is free to prescribe whatever they want Presumably not "whatever they want", presumably it's a bit more structured then that. > The third party payer is also free to object Aren't the patients payers too? Read the article, it's nice.
- erentz 7y ago> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules. I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that goes against the doctors judgement then that is a decision they made to trump that doctors judgement. This kind of “just following orders” logic is used a lot by people who want to absolve themselves of the responsibilities of their choices.
- lotsofpulp 7y ago>They also have the ability to override the policy. From my understanding, they do not. At least not outside of a certain margin of error, since the payer (for example a state government or employer) would then blame the PBM for approving payment something it wasn't supposed to approve payment for, and hence seek reimbursement from the PBM or cancel its contract and go with another PBM.
- erentz 7y agoI’ve had specialty medicine approved that very clearly goes against policy at different phases of the review process (including immediately) on different insurance plans. So they do seem to me to have this power.
- lotsofpulp 7y agoI can't answer for why they would violate the policies they are supposed to be enforcing, but I do no know PBMs get audited by governments and penalized for improperly approving medications for Medicaid recipients.
- darkerside 7y agoWhat do you think is happening during the appeals process?
- dylz 7y agoFor almost everyone in the US, is it not true that "claim for medicine is covered under the plan rules" being denied is effectively "you are not getting this medication"?
- lotsofpulp 7y agoI guess, but the nuance is that the PBM is only doing what the payer wants it to do. If a state tells the PBM to only approve payment for certain medications under certain circumstances, I don't see the purpose of blaming the PBM for this. Similary, if an employer chooses a formulary that results in a denial of payment, it's the employer who chose to not cover payment for the medicine. The state or the employer can choose to pay for the medicine, but that is not up to the PBM.
- maxerickson 7y agoAnd the payer can state that the PBM only offers a limited set of options, each hand washing the other.
- lotsofpulp 7y agoThe payer cannot state that, but they do have limited funds so they're not able to say "approve every prescription". Payers are not forced to use PBMs, they choose to to achieve their goals, such as staying within their budget. My whole point is that blaming PBMs is a waste of time. With or without PBMs, someone working at or for the payers (employers, insurers, governments) will be approving and denying claims, just like they have to for home and auto and any other insurance claim. The correct person to blame is us, the voters, for not voting for taxpayer funded healthcare for everyone. But even then, there will probably be some type of setup to ensure healthcare providers are not abusing and defrauding the system, hence someone to approve and deny payment from the government.