4 ms·
For 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 me
by dylz 7y ago
For 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.