MES Certification Navigator
PBM

Pharmacy Benefit Management

Pharmacy Benefit Management (PBM) systems provide services which may include claims adjudication, rebate administration, utilization monitoring, drug utilization review, and preferred drug list oversight.

CMS-Required Outcomes (9)

RefOutcomeSources
PBM1The system adjudicates claims within established time parameters to ensure timely pharmacy claims payments.
42 CFR 456.722Section 1927(h) of the SSA
PBM2The system adjudicates claims accurately within established parameters. The module can be configured to provide authority/ability to override a reject/edit/denied claim and then resubmit to ensure timely provider claims payments.
42 CFR 456.722
PBM3The system captures the necessary data to ensure timely processing of manufacturer rebates as well as the capability to track rebates to promote beneficiary cost savings.
42 CFR 447.509Section 1927 of the SSA
PBM4The system has the capability to support cost savings by capturing, storing, and transferring data to the payment process system to generate invoices of participating drug manufacturers within 60 days of the end of each quarter.
42 CFR 447.52042 CFR 447.511Section 1927 of the SSASection 1927(b)(2) of the SSA
PBM5The system supports cost savings by enabling the tracking, monitoring, and reporting of manufacturer's pharmacy drugs and rebate savings.
42 CFR 447.52042 CFR 447.511Section 1927 of the SSASection 1927(b)(2) of the SSA
PBM6The system enables the beneficiary to have timely access to medication if the system has the capability to perform prior authorization and provide a response by telephone or other telecommunication devices within 24 hours of a request and provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (unless excluded under the SSA ).
Section 1927(d)(5) of the SSA
PBM7The system supports CMS oversight of the safe, effective, and appropriate dispensing of medications by enabling the capability to provide data to support the creation of the CMS annual report on the operation and status of the state's DUR program.
42 CFR 456.712Section 1927(g)(3)(D) of the SSASection 1944(e)(1) of the SSA
PBM8The system supports the safe, effective, and appropriate dispensing of medications by enabling the capability to provide point-of-sale or point of distribution prospective review of drug therapy based upon predetermined standards, including standards for counseling.
42 CFR 456.703Section 1927 (g) of the SSA
PBM9The system supports the identification of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, or prescribing or billing practices indicating abuse or excessive utilization among physicians, pharmacists and individuals receiving benefits by enabling the collection of pharmacy data to be used in retrospective drug utilization reviews.
42 CFR 456.703Section 1927 (g) of the SSA

State-Specific Examples (3)

Outcome statements from other states, gathered and shared by CMS in the certification repository — the best available reference for drafting your own.

OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.

The Single Pharmacy Benefit Manager (SPBM) module will provide accurate and timely processing of pharmacy claims utilizing fully transparent pricing and payment methodologies as determined by the Ohio Department of Medicaid.

Metrics
  • Assessed through the daily concurrent claims reviews conducted by ODM's Pharmacy Pricing and Audit Consultant (PPAC). Reporting will be available no later than one quarter after go live and will be continuously monitored throughout the operational life of the module.
OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.

The Single Pharmacy Benefit Manager (SPBM) module will improve the accuracy and timeliness of the acquisitions and integration of pharmacy claims encounter data.

Metrics
  • Assessed through the comparison of pre and post processing of pharmacy encounter claims, including measures such as the time from date of payment to date of encounter submission and percent of encounter claims rejected for data quality issues. Reporting will be available no later than one quarter after go live and will be continuously monitored throughout the operational life of the module.
OHTo support the implementation of a more efficient and cost effectivfe operating model to deliver pharmacy benefits to Ohio Medicaid members.

The Single Pharmacy Benefit Manager (SPBM) module will reduce the overall benefits and administrative costs of the Ohio Medicaid pharmacy program.

Metrics
  • Assessed through the comparison of pre and post implementation expenditures on pharmacy benefits and administration. Reporting will be available no later than two quarters after go live and will be monitored until a new budgetary baseline is established.