What is a function that Pharmacy Benefit Managers do NOT typically perform?

Pharmacy Benefit Managers (PBMs) are organizations that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. One of their key functions is to develop and manage formularies, which are lists of covered drugs that need to be approved for reimbursement. This involves creating drug formularies based on various factors, including efficacy, safety, and cost, to ensure that patients have access to necessary medications while controlling costs for payers.

PBMs play a crucial role in negotiating discounts and rebates with pharmaceutical manufacturers to lower drug costs for insurance plans and consumers. By leveraging their purchasing power, they can significantly reduce the prices that insurers pay for medications.

Processing prescription claims is another critical function of PBMs. They handle the adjudication of claims for medications, ensuring that prescriptions are accurately billed and that the appropriate costs are applied based on the insurance benefits.

Direct hospital admissions, however, fall outside the typical responsibilities of PBMs. This function is usually managed by healthcare providers and hospitals rather than PBMs, as they focus on pharmacy benefits and related aspects of healthcare rather than the overall hospital admission process.