Insurance Systems in Pharmacy/PBM

[marscole]

Advertisement - Members don't see this ad

Recently, I received an email from the company that the PBM is switching to CVS Caremark, effective beginning 1/1/2015. And my rotation site, is switching to MedImpact as well.

I don't quite understand the whole insurance system/concept. What is this all about? I'm confused. Why switching to this insurance or that or whatever....

Anyone can explain this complex stuff please? It's not taught in pharmacy school... 🙁

 

[JustAnotherRph]

Each insurance plan uses a claims processor for their pharmacy benefits. Most PBM's "own" their claims processor, but several smaller PBM's contract out with other PBM's. For instance, we contract out our Medicare business to be processed through Argus but our own Medicaid and Commercial business use our own claims system. When I used to work for a larger insurance plan, we utilized Express Scripts but then switched to CVS/CMK to process our pharmacy claims.

All it means for you is that you have to learn a new system. It should still work business as usual.