Virtual PBM: Increasing payer control over pharmacy benefits

Oct 31, 2023

There is no such thing as a one-size-fits-all solution in healthcare. At least, not a successful one. Yet, as the industry consolidates, payers are finding themselves with fewer options and less flexibility.

Now more than ever, payers need to be able to pursue the technology, partners, clinical programs, pharmacy networks, etc, that provide the most value–and best possible experience–for their members.

Enter the Virtual PBM model. This integrates multiple vendors that each support, and coordinate, traditional PBM responsibilities through a central technology hub. Here’s how this approach gives health plans greater control over their pharmacy benefits:

  • Choice over vendors and partners. Rather than being tied to a single, full-service PBM, the Virtual PBM model allows payers to select best-in-class partners to manage single or multiple pharmacy benefit management functions. For example, a plan could select separate partners to execute home delivery, rebates, claims processing, and specialty pharmacy.
  • The ability to take PBM functions in-house. The Virtual PBM model empowers payers to manage PBM functions in-house based on their internal capabilities. For example, some organizations may be better equipped to insource rebate management rather than reporting or claims adjudication.
  • Aligned incentives. In the Virtual PBM model, the success of each partner is deeply intertwined with that of the others. As such, every entity is working towards common goals, including delivering the best possible member experience.
  • Transparency. An advanced, centralized technology hub serves as the engine that powers any Virtual PBM agreement. Since every partner will use the same platform to share information, process claims, and generate reporting, information across vendors is consistent and transparent.
  • Reduced conflicts. Working with a vertically integrated PBM often requires plans to partner with a competitor. Through a Virtual PBM model, payers are empowered to work with independent organizations–helping to preserve proprietary information.

At Abarca, we believe that payers should have to flexibility to choose how to manage their pharmacy benefit, and whom they want to partner with.

And, through the Virtual PBM model, they can do just that while providing a better experience–for employees, prescribers, partners, and consumers–and facilitating seamless and personalized healthcare for everyone.

This blog was written by Jesse Ruzicka, Senior Vice President of Sales at Abarca.