Pharmacy Benefit Managers

Healthcare payers increasingly depend on specialized organizations to administer and manage various aspects of member benefits. Among the most influential participants in the pharmacy ecosystem are Pharmacy Benefit Managers (PBMs), which oversee prescription drug programs for health plans, employers, government agencies, and other healthcare organizations. Acting as a vital intermediary, PBMs coordinate interactions among health plans, pharmacies, pharmaceutical manufacturers, and members while managing prescription drug benefits on behalf of the insurers. Although PBMs are primarily responsible for pharmacy benefit administration and claims adjudication, Oracle Revenue Management and Billing (ORMB) plays an essential role by managing the financial relationships, billing processes, and settlement activities that underpin PBM operations.

The pharmacy benefit ecosystem involves multiple stakeholders, such as:

• Members (Patients)

• Healthcare Providers

• Pharmacies

• Pharmaceutical Manufacturers

• Health Plans

• Pharmacy Benefit Managers (PBMs)

• Financial and Billing Systems

Based on the above stakeholders, pharmacy benefit ecosystem contains the following payment and billing mechanisms:

• Pharmacy Payment

• CAG Billing

Parent topic: Oracle Revenue Management and Billing Insurance Business Processes