PBM Denials Explained: When Your Insurance Company Isn't Making the Decision

You got denied by your insurance company, but when you call to appeal, you discover that a company you have never heard of actually made the decision. This is how pharmacy benefit managers work, and it affects your appeal strategy.

Most large insurance plans contract with a pharmacy benefit manager (PBM) to handle prescription drug coverage decisions. The three largest PBMs control approximately 80 percent of the market: CVS Caremark, Express Scripts (owned by Cigna), and OptumRx (owned by UnitedHealth). Understanding this structure can help you direct your appeal to the right place and understand why your denial letter may reference companies or policies you did not know were involved in your coverage.

Ellen can help you identify the PBM behind your denial and tailor your appeal strategy accordingly. Start here →