What is the role of a pharmacy benefit manager (PBM)?

The role of a pharmacy benefit manager (PBM) is primarily to process and pay for drug claims. PBMs act as intermediaries between insurance providers, pharmacies, and drug manufacturers, managing prescription drug benefits for health plans. They ensure that when a patient fills a prescription, the claim is processed in accordance with the rules of the insurance plan, including verifying coverage and pricing for the medication.

PBMs negotiate with pharmaceutical companies to obtain rebates and discounts, helping to manage costs, and they also establish formularies—lists of covered medications that align with the health plan's strategy. When a claim is submitted, the PBM plays a crucial role in determining the patient’s coverage for that specific drug and ensuring that payments are processed correctly and efficiently.

The other choices relate to different aspects of healthcare management but do not accurately reflect the primary responsibilities of a PBM. Health insurance policies are provided by insurance companies, patient eligibility is determined by health plans or insurers, and procedures for surgeries are typically approved through different medical management systems, which are not within the PBM's scope of functions.