Licensing & Credentialing
Pharmacy Benefit Manager
PBM
A third-party company that administers prescription drug benefits for health plans - processing claims, setting reimbursement, and contracting with pharmacies through their networks.
In depth
PBMs sit between pharmacies and payers: they adjudicate claims, set formularies and reimbursement, and decide which pharmacies are in-network. To join or stay in a network, a pharmacy must be credentialed by the PBM and keep that credentialing current. PBM contracts also drive concepts like DIR fees and audits, which is why PBM credentialing and audit-readiness are core compliance workstreams.