Medco, Caremark, pharmacy-benefit management companies, as a patient, how does it work?

Question

I have health insurance coverage by Anthem. Recently I've been reading about Pharmacy Benefit Managers and how a lot of their business is Mail order. I read they squeeze margins and take away business from retail pharmacy. But what I don't understand is, from a patient's perspective, how does this work? Do they have their insurance like Anthem, and then also Medco? Or is Medco their insurance? So a patient goes to their doctor and gets a prescription. Usually they'd then go to their pharmacy and pick it up, pay a co-pay while their insurance covers the rest. Where does Medco come in with their competing mail order? What's the difference between health insurance and these pharmacy benefit managers? Please keep your answer in the perspective of the patient. I've read about it from the business angle and I'm confused as hell to how it works. Thanks in advance!!

Answer 1

Pharmacy benefit management companies are employed by your health insurance company to manage your pharmacy benefits. Anthem, for example, offers their own PBM- Anthem Rx. Depending on your company, Anthem Rx may or may not be your PBM.
Anthem does offer mail order Rx program. What you need to do to find out about your mail order service is to call the customer service number on the back of your prescription insurance card. They will be able to give you all the information you need to know. Most mail order business is for people on maintenance-type drugs like blood pressure or cholesterol. They fill 90 day supply prescriptions. So, if you take something like that, a mail order company may be able to help you.
But if you're just filling antibiotics, you should just go to your local pharmacy.
Look at the PBM as just an outside company that your insurance plan has chosen to handle your pharmacy benefits. Like I said, since you have Anthem health insurance, your PBM may or may not be Anthem. For example, I have Blue Cross/Blue Shield of RI and my PBM is Pharmacare. Contact the number on the back of your card for specific info.

Answer 2

A Pharmacy Benefit Manager (PBM) is an entity contracted with a carrier that only administers the plan's pharmacy benefit. Insurers sometimes use a similar arrangement for the administration of the policy's mental health / substance abuse benefits. Your carrier is still technically your insurer.

PBM's usually offer mail order service. In some states, such as mine, PBM's cannot require an insured to use mail order service; they must be given the option to go to a pharmacy. If this is a concern with you, check with your state insurance commissioner' office. However, if your plan is "self-funded" by your employer, state insurance law doesn't apply.

When using a PBM's mail order service, the prescription is sent to it, either via fax, phone or mail; the order is filled and shipped; and the patient is billed for the co-pay, co-insurance or any other applicable charges.

Sometimes PBM's give a separate card to insureds, sometimes they don't -- it depends upon the arrangement the PBM has with the carrier.

I hope this helps.

Answer 3

If you're on maintenence medication - like for asthma or high blood pressure or something like that - it sometimes can work out to do mail order - you get a three months' supply of medication either for a copay and a half or two copays. For things like antibiotics or short-term treatments, it doesn't pay because it's often a few days before you actually get the medication.

IMO - the only thing that stinks about them is not being able to have the prescriptions quickly. Sometimes people run out of medication unexpectedly (they lose count or something) and these places can't get them out as fast as a local pharmacy.