In PBM claim adjudication, which step determines the amount of the patient's price?

In PBM claim adjudication, which step determines the amount of the patient's price?

• A. Price determined
• B. Verify belongs to member
• C. Verify it's on formulary
• D. DUR electronically determined

Answer: (A)

The amount the patient pays is determined at the price determination step. This is the stage where the PBM applies the member’s benefits to the drug—considering formulary status, the plan’s negotiated pricing, the drug’s tier, and the patient’s cost share (copay, coinsurance, deductible, etc.)—to calculate the exact out-of-pocket amount. Other steps don’t set the price: verifying the member confirms eligibility, verifying formulary status checks whether the drug is covered and at what tier but doesn’t compute the exact patient cost, and DUR checks evaluate safety and appropriateness rather than price.

The amount the patient pays is determined at the price determination step. This is the stage where the PBM applies the member’s benefits to the drug—considering formulary status, the plan’s negotiated pricing, the drug’s tier, and the patient’s cost share (copay, coinsurance, deductible, etc.)—to calculate the exact out-of-pocket amount.

Other steps don’t set the price: verifying the member confirms eligibility, verifying formulary status checks whether the drug is covered and at what tier but doesn’t compute the exact patient cost, and DUR checks evaluate safety and appropriateness rather than price.