Which entity is most likely to administer the prescription drug benefit for a health plan?

• A. Health Plan's Internal Team
• B. Hospital Pharmacy
• C. Pharmacy Benefit Manager
• D. Insurance Broker

Answer: (C)

Managing the prescription drug benefit requires specialized coordination across formularies, prior authorizations, step therapy, networks with pharmacies, and processing drug claims, all with an eye toward cost control and appropriate patient access. A Pharmacy Benefit Manager is designed for that role, acting as the intermediary between the health plan, pharmacies, and drug manufacturers. They design the benefit—deciding which drugs are covered and at what copays—establish utilization rules, negotiate rebates, maintain pharmacy networks (retail and mail order), and handle claims adjudication. This centralized expertise makes the prescription drug benefit scalable and consistent across members and providers.

An internal health plan team might handle some aspects, but outsourcing to a PBM is the standard approach for broad, cost-effective drug benefit administration. Hospital pharmacies manage medications for patients within a hospital setting, not the plan-wide benefit. An insurance broker sells plans and helps with enrollment; they do not administer the ongoing drug benefit.