Frequently Asked Questions
Prescription Drug Benefit
(Pharmacy Benefit Manager)
What is a Pharmacy Benefit Manager
(PBM)?
A PBM is a third party administrator of a prescription drug program
that is primarily responsible for processing and paying prescription
drug claims. In addition, they develop and maintain the formulary,
contract with pharmacies, and negotiate discounts and rebates
with drug manufacturers. Navitus negotiates rebates and discounts
on behalf of the State of Wisconsin and passes the savings back
to the State. Many health plans provide their drug benefit through
a PBM.
Who will be required to use the PBM?
All participants in the State of Wisconsin group health insurance
program, including State employees and annuitants, continuants,
graduate assistants, and local government employees and annuitants,
will receive their pharmacy benefits through the PBM regardless
of the health plan they have chosen. This will allow ETF to administer
pharmacy benefits uniformly for all group health insurance participants.
How does having one PBM benefit participants
in the health insurance program?
An advantage to one PBM is having the ability to offer initiatives
that give value and flexibility to participants, such as tablet
splitting, sampling and a mail order service. In addition, having
a larger purchasing pool for prescription drugs allows our PBM
to negotiate rebates and discounts on behalf of the State of Wisconsin
and pass the savings back to the State. This may help hold down
future cost increases.
What should I do if I have a problem
getting my prescriptions filled, have a denied pharmacy claim, or
a complaint about my pharmacy benefits?
Contact the PBM for all pharmacy benefit questions and concerns.
If you are dissatisfied with the PBM's resolution to a problem,
you have the right to file a complaint with the PBM. If you remain
dissatisfied with the PBM, you may request a ETF administrative
review.
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