Which type of PBM service agreement involves a per-employee fee regardless of claims experience?

A capitated service agreement with a pharmacy benefits manager (PBM) is characterized by a fixed fee per employee, which remains constant regardless of the actual claims experience or the level of services utilized. In this model, employers pay a predetermined amount to the PBM for each enrolled individual, thus providing predictable budgeting and cost management for employers.

Under this arrangement, the PBM assumes financial risk for managing pharmacy benefits, as their compensation does not vary with the number or cost of claims processed. This can simplify the payment structure for employers and provide a clear understanding of health benefits expenses over time.

In contrast, the other types of PBM service agreements often have compensation structures that are linked to claims experience or actual services rendered, which means costs can fluctuate based on utilization and outcomes. This differentiates the capitated model as a more fixed-cost approach to managing pharmacy benefits.