In a capitated contract, what role does the PBM fulfill?

In a capitated contract, the role of the pharmacy benefit manager (PBM) aligns most closely with that of an insurer. Under a capitated payment model, a set fee is paid to the PBM per member for a specified period of time, regardless of the actual number of services provided. This means that the PBM assumes financial responsibility for managing the pharmacy benefits and must effectively control healthcare costs while ensuring that patients receive necessary medications.

As the insurer in this context, the PBM coordinates care and manages pharmacy costs, including negotiating drug prices, establishing formularies, and processing claims. This helps streamline the accessibility and affordability of medications for members. Given that the PBM is managing risks and financing aspects associated with drug benefits, this role is quintessentially that of an insurer rather than a mere consultant, broker, or dispenser, which involve different responsibilities and financial arrangements.