Pharmacy Benefit Management

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Pharmacy benefit managers (PBMs) act as a mediator between you (the payer) and all other departments in the healthcare system. They help you manage the cost of your employees’ prescription drug plans by contracting with pharmacies and negotiating rebates and discounts with drug manufacturers. PBMs also help you with administrative tasks such as processing and paying prescription drug claims.

The majority of PBMs work with self-insured companies and government programs who want to manage pharmacy expenses and maintain quality healthcare for their employees. While most PBMs work the same way, you should know how they work so you can determine if using one can save your company money.

Top 10 Best Rated Pharmacy Benefit Management

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Founded in 1986, Express Scripts is headquartered in St. Louis, Missouri and offers home-delivery pharmacy and specialty pharmacy services management. Today, it employs over 30,000 people worldwide with plans to expand.

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Caremark is a division of the retail pharmacy CVS, which helps customers with prescription benefits. They work with employers, medical plan providers and pharmacists, in addition to medical professionals.

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Founded in 1989 and headquartered in Irvine, California, OptumRx is a healthcare management company offering pharmacy benefit management solutions. It has served over 67 million consumers and processed more than 1 billion claims.

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Argus is a pharmacy benefit management company based in Kansas City, Missouri. It supports its clients and healthcare organizations with services like drug management, claims and pharmacy network solutions.

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Based in Twinsburg, Ohio, EnvisionRxOptions is a pharmacy benefit management and healthcare company. Its pharmacy network gives clients multiple discounted drug plans to choose from.

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ProCare Rx provides computer software systems and services to the healthcare industry. Today, through a series of acquisitions, they provide a full spectrum of PBM services and resources.

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MedImpact is a pharmacy benefit manager based out of San Diego. It focuses on working with your health plan and various pharmacies to make sure your healthcare plans are affordable while still maintaining quality.

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Founded in 2003, Navitus Health Solutions is a full-service pharmacy benefit management company headquartered in Madison, Wisconsin. It focuses on improving health while lowering drug costs and providing quality PBM service.

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Founded in 1982, Cigna is a global health services company headquartered in Bloomfield, Connecticut. It offers health insurance and pharmacy benefit management solutions to over 75 million customers worldwide.

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Citizens Rx is a full-service pharmacy benefit management company for private and public companies. It has a pharmacy network of over 67,000 and a list of unbundled pharmacy services and solutions.

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    Jonathan Trout

    ConsumerAffairs Research Team

    As a member of the ConsumerAffairs Research Team, Jonathan Trout believes having access to free, comprehensive information on products and businesses is vital to making smart purchasing decisions. He focuses his efforts on researching and reviewing multiple brands across a variety of industries, with the goal of writing unbiased buyers guides to help inform consumers on impending purchases.

    What do pharmacy benefit managers have to offer?

    How does a PBM’s pharmacy network benefit you?

    One of the most important parts of a pharmacy benefit management company is their pharmacy network. A PBM’s pharmacy network is made up of pharmacies that have contracted with the PBM to provide prescription drugs to people with eligible health care plans.

    • Preferred networks: PBMs direct clients to pharmacies in preferred networks who offer lower drug prices in exchange for higher volume. Most plans let a beneficiary choose any provider, but they use incentives to encourage people to choose providers within the preferred network.
    • Open networks: Open networks are made up of any pharmacy willing to sign a contract for a predetermined payment level.
    • Claim processing: PBMs are responsible for processing and paying prescription drug claims within their network of pharmacies.
    • Dispensing fees: PBMs negotiate dispensing fees with pharmacies in their network to lower costs. Many PBMs can get as much as $1 below the normal dispensing fee per prescription.

    What are some benefits of mail-order pharmacies?

    Some PBMs use mail-order pharmacies to help manage prescription drug costs and improve the value of your company’s drug benefit plan. Mail-order pharmacies provide multiple benefits for your employees. They can save your employees time and money, help them manage their prescriptions and provide access to pharmacists.

    • Save money and time: Most drug prescription plans offer discounted drugs if they’re ordered online and delivered to your home. For example, your employees could order a three-month supply of certain medications giving them fewer refills and lower out-of-pocket costs.
    • Manage ongoing medications: Chronic conditions like high cholesterol and high blood pressure require your employees to stick to a strict medication schedule. Mail-order pharmacies can setup automatic refills so they never miss a day.
    • Access to pharmacists: Most online pharmacies give your employees 24/7 access to a pharmacist should any questions come up.

    What role do pharmacy benefit managers play in your formulary and drug plans?

    Pharmacy benefit managers consult with panels of independent doctors, pharmacists and other clinical experts to make lists of drugs that are approved for reimbursement (formularies). This helps encourages cost-effective prescribing while making sure drugs are clinically appropriate. Employers or health plan providers who use a PBM clients have the final say on which drugs are included on the formulary.

    • Plan design: PBMs help you structure your prescription benefit plan to encourage the use of lower-cost drugs like generics. But you have the final say; the PBM is strictly an advisor as you design a prescription drug plan.
    • Copay tiers: You can encourage employees to use low-cost drugs by setting up plans with different copay tiers. Your employees would get a lower copay for generic drugs and a higher copay for brand-named drugs.
    • Step therapy: Many formularies and drug plans use step therapy to reduce costs. This practice treats a medical condition with cheaper medication or therapies to start, then progressing to more costly, riskier medications or therapies if necessary.

    What are the benefits of specialty pharmacy services?

    Specialty drugs like high-cost biotech prescription drugs require special ordering, handling and administration. A lot of specialty drugs are injectable and require special handling and training for people who administer them. A PBM offering specialty pharmacy management services helps manage the high costs of these medications and helps determine treatment plans and therapies for your employees. Specialty pharmacy services include:

    • Dosage and quantity verification: PBMs should monitor dosage and quantities of all specialty drugs to ensure patients are taking the correct amount.
    • Patient education: Specialty pharmacy drugs are expensive and complex. They often come with strict instructions on how to administer and take them. Properly educating patients makes sure the medicine is taken correctly.
    • Clinical monitoring: Clinical monitoring and support helps reduce health risks and potential serious side effects by making sure patients know how to administer their own medication properly.

    What are some operational solutions that pharmacy benefit managers provide?

    Pharmacy benefit managers can help you streamline the administrative side of your operations. Using technology to digitize processes gives you smoother transactions with providers, health plans and consumers. The simple process results in higher-quality, more efficient service.

    • Billing and claims: Many PBMs use billing and claims processing software that integrates across multiple platforms. This lets physicians, patients and health plan providers connect with each other so everyone stays in the loop. The automated workflow speeds up the reimbursement process, keeping patients satisfied.
    • On-demand customer service: On-demand customer service lets PBMs go above and beyond for patients when they call the number on the back of their prescription card. Through integrated technology, the agent on the phone can access each patient's comprehensive health care plan. This lets them recognize any unmet needs to make sure potential problems don’t come up.
    • Member engagement: PBMs use mobile apps to keep members engaged through personalized tools. Apps give members the power to easily manage their own healthcare. They can refill prescriptions, schedule home delivery, find low-cost drug prices and locate a pharmacy all from their smartphones.

    What types of accreditation do pharmacy benefit managers have?

    Licensing and accreditation are important attributes to consider when looking for a pharmacy benefit manager. PBMs should be licensed for all states where they operate. Two common organizations that accredit PBMs are the Utilization Review Accreditation Commission (URAC) and the Accreditation Commission for Health Care (ACHC).

    • URAC Pharmacy Benefit Management: URAC PBM accreditation is the most common for pharmacy benefit managers. URAC makes sure PBMs focus formulary choices on the safety and therapeutic needs of consumers before focusing on the cost of drugs. It ensures PBMs remain transparent with pricing and contracting.
    • URAC Drug Therapy Management: URAC accredits PBMs for Drug Therapy Management programs. It makes sure companies who provide and administer medical treatment plans do so in a safe and transparent way, making sure the patient’s safety comes first.

    What are your options when choosing a pharmacy benefit manager?

    Third party carve-out

    A third party carve-out is also referred to as a standalone PBM, meaning it’s separate from an insurance carrier. This is a popular option since a standalone PBM is flexible. You can plan your own formularies and drug plans and have more control over the contract terms. As the employer, you save more money by cutting out the middleman. Most insurance carriers who bundle prescription and medical plans use a third party PBM.

    Bundle the PBM with your medical insurance carrier

    Bundling your PBM with your insurance carrier is the simplest route to take. You’re only dealing with one carrier, one contract and one service team. Bundling reduces the flexibility offered with standalone PBMs and you can’t control the terms of the contract with the PBM. You also don’t have control over formularies and drug lists.

    Third party carve-out through a consortium

    These PMBs bring back the middleman in the form of a broker or industry cooperative. While this could mean big savings for your company, you lose flexibility and control over things like contract terms and formularies.

    Who can benefit from a pharmacy benefit management company?

    Consumers

    In a nutshell, PBMs make sure the consumer sees low, discounted drug costs. They negotiate with drug manufacturers and pharmacies to secure discounts on drugs. These discounts and savings are passed down to your insurance company who, in turn, are able to set a smaller copay and premium that you’ll pay when you get a prescription filled.

    Insurance companies

    As an insurance company, you pay a PBM to manage your drug costs. The PBM negotiates drug prices with manufacturers and pharmacies on your behalf. The PBM also makes sure you get rebates from drug manufacturers.

    Drug manufacturers

    If you’re a drug manufacturer, you can use your relationship with PBMs to get your drug recognized. Through negotiations with PBMs, manufacturers give discounts in exchange for getting their drug in front of millions of people.

    Employers

    As an employer, using a PBM can help you improve the health and productivity of your workforce while reducing your costs. PBMs will help your employees get more involved in managing their own health care through integrated technology, mobile apps and real-time customer service. They’ll also help you design drug plans and make a formulary.

    Pharmacy benefit management company reviews

    Argus

    As a pharmacy benefit management company (PBM), Argus offers cost-effective and flexible solutions to its clients in the healthcare industry. Acting as the middleman between clients and the healthcare system, Argus processes prescription drug claims, offers specialty drug management solutions, administers government programs like Medicare and Medicaid and more.

    • Government programs administration: As an Argus client, you can get help with enrollment, administrative and care management services for Medicare and Medicaid. You will have a team dedicated to all things related to Medicare Part D, including medication therapy management (MTM) and coverage determination. Argus’ Medicaid solutions include formulary management, rebate administration and MTM.
    • Specialty drug management: Argus offers three specialty drug management tools and services. These tools help health administrators improve spending and manage quality of care. Argus works with health plans to come up with customized medical drug management strategies to meet each health plans’ unique needs. Its specialty drug management solutions also help you customize site-of-care strategies and specialty pharmacy needs.
    • Formulary and rebate management: Argus uses formulary processes to determine guidelines for safe medication use, control drug expenses and maximize rebates. It also helps minimize the risks of increased drug prices by implementing a maximum allowable price on most brand name drugs available for rebates.
    • Pharmacy network solutions: Argus’ network services include over 67,000 retail pharmacies. This includes all major pharmacy chains and around 20,000 independents. It partners with the best pharmacy providers in the industry for the most competitive retail rates. If your business requires multiple pharmacy networks, Argus can support you as well.
    • Discount drug card program: Members who use your Argus’ Drug Discount Card (DDC) get access to the Argus National Pharmacy Network, giving them significant discounts and cheap generic drug options.
    • Best for: employers needing help managing their healthcare plans and prescription drug plans.

    EnvisionRXOptions

    EnvisionRXOptions is a pharmacy management benefit company based in Twinsburg, Ohio. Acquired by Rite Aid in 2015, it now creates savings for more than 23 million members. Thanks to its large network of pharmacies, members enjoy more pharmacy options. Plan sponsors enjoy tailored programs that help labor groups and employers meet their goals of staying on budget while providing quality care.

    • Pharmacy benefit management: Envision’s PBM services include three options: EnvisionRx, MedTrakRx and HospiceRx. As a plan sponsor, EnvisionRx lets you pay a simple administrative fee for program management and earn discounts back at the point of sale on your prescriptions. MedTrakRx is designed to meet the needs of small- and medium-sized businesses with custom drug plan designs. HospiceRx focuses on end-of-life care and the highly regulated drugs that come with it.
    • Pharmacies: Envision has a large network of retail, independent, specialty and mail-order pharmacies. It contracts with more than 72,000 retail pharmacies across the United States, including Rite Aid locations. Envision’s specialty pharmacy supports people with rare and complex conditions who need specialized, ongoing care and therapies. Members who have chronic conditions that require regular prescriptions benefit from Envision’s mail-order pharmacy. It’s convenient, easy and secure.
    • Savings programs: Envision offers two savings programs: EnvisionSavings and DesignRx. EnvisionSavings works with plan members to get them discounts on multiple drug types, including brand name prescriptions. DesignRx is one of the largest discount fertility programs in the United States. It gives members access to lower-cost fertility drugs.
    • EnvisionInsurance: EnvisionInsurance works through the EnvisionRx PBM plan and offers Medicare Part D plans to qualifying members. It currently has over 400,000 members in the United States.
    • Accreditation: Envision is accredited by the Utilization Review Accreditation Commission (URAC) for PBM and Drug Therapy Management. URAC accreditation ensures members receive quality health care.
    • Best for: labor groups and employers wanting to provide quality healthcare for their employees while saving money.

    ProCare Rx

    ProCare Rx got its start in 1987 processing claims for the healthcare industry. After a series of acquisitions, it now provides labor groups and employers with a full range of PBM services and solutions. It has a network of over 65,000 pharmacies across the United States, including mail-order and specialty pharmacies.

    • Mail-order pharmacy: ProCare PharmacyCare (PPC) is a mail-order and specialty pharmacy geared towards optimizing drug therapies. PPC uses quality assurance checks and an automated system and makes sure each prescription is checked by a real pharmacist. Members can easily refill multiple prescriptions online using their membership information and prescription numbers.
    • Hospice services: ProCare HospiceCare (PHC) helps you manage hospice medications and gives you access to the lowest possible cost. PHC services include developing and managing a preferred drug list tailored for your individual needs. It helps you negotiate medication discounts and delivery fees and process and pay prescription claims.
    • Specialty pharmacy: If you need ongoing treatment for a rare condition, ProCare Rx’s specialty pharmacy helps you manage the high cost of specialty medications and therapy. It helps you verify dosage and quantity, coordinate benefits for use with coupons and vouchers, and provides you with free drug administration supplies.
    • Pharmacy on-demand: ProCare Rx can install MedCenter kiosks that allow members to fill prescriptions fast from any location, at any time, while connecting with remote pharmacy staff through video conferencing. Using a touchscreen, a member can start the process and follow prompts. Pharmacy staff authorize the kiosk's robotic arm to get, verify and label medications according to the scanned or stored prescription.
    • Accreditation: ProCare Rx holds two accreditations from URAC, one in pharmacy benefit management and one in mail service pharmacy.
    • Best for: employers wanting a full service PBM with multiple options.

    MedImpact

    MedImpact is a pharmacy benefit manager based in San Diego. It delivers low-cost, high-quality care when working with your health plan and pharmacies to get you the medication you need. MedImpact helps you get important information about your medicine, like how to take it correctly, potential side effects and any low-cost options like generics.

    • MedImpact Direct: MedImpact Direct is Medimpact’s mail-order pharmacy and will deliver your medication to your front door. After you set up an online account, you can call in, mail order or have your doctor send your prescription. You can also order refills online or over the phone.
    • Claims processing: As a plan sponsor, you can get real-time access to your claims using MedImpact’s claims management system, MedAccess. With MedAccess, you have desktop access to things like real-time prior authorizations, eligibility edits and member reimbursements.
    • Specialty management: MedImpact’s Direct Specialty gives you start-to-finish specialty drug management. It monitors high-cost drug trends to make sure you are getting the lowest cost possible. MedImpact doesn’t own specialty pharmacies. It goes through a small network of specialty pharmacy providers to help lower your costs through deeper discounts.
    • New solutions: MedImpact continuously innovates and implements new solutions to deliver the best quality care. iRx Program® integrates medication discounts with existing prescription plans to keep members from paying the full price for prescribed medications. Its Refill Reminder Program uses Interactive Voice Response (IVR) to call members who are late refilling their prescriptions. This program targets members with clinically important medications like diabetes, hypertension or cholesterol patients.
    • Accreditation: In April of 2017, MedImpact renewed its accreditation for pharmacy benefit management with URAC.
    • Best for: prescription plan providers who want multiple PBM services and solutions to choose from.

    Express Scripts

    Express Scripts is the largest pharmacy benefit management organization in the United States. Acting as the middleman between drug makers and employers, it provides services such as home delivery, specialty pharmacy management and prescription benefits for self-insured companies. Express Scripts also publishes an annual Drug Trend Report that details prescription drug costs and utilization.

    CignaHealth-Cigna Pharmacy Management

    Known as a health insurance provider, Cigna also offers pharmacy benefit management services and solutions. It focuses on integrating drug benefits with medical and behavioral benefits to provide more personalized customer experiences.

    • Keeping costs down: Cigna helps you control costs associated with your drug plans by using strategies like generic-first prescribing practices and free home delivery. It coaches customers on their medical conditions and provides benefit counseling (live and online) to help make customers make financially smart decisions when choosing a drug plan.
    • Prescription drug price quote tool: As a member of Cigna’s PBM, your employees will have access to a prescription drug price quote tool. Use this tool to find real-time search results on lower-priced drugs and pharmacies.
    • Coach Rx: Coach Rx is a program that flags high-risk customers to make sure they adhere to their prescription refill schedules. High-risk customers are people with chronic conditions like diabetes and hypertension.
    • Specialty pharmacy: Do you have a chronic or rare condition that requires specialty drugs or therapy? Cigna understands that specialty products need to be shipped with care and in the right condition. It also provides therapy management services that help you coordinate your refills and answer any questions related to your medication.
    • Home delivery pharmacy: Benefits of Cigna’s home delivery pharmacy include automatic refill reminder service, free delivery and the ability to speak with a licensed pharmacist 24 hours a day. Depending on your plan, you may be able to get three months of medication at a discounted rate of two or two and half times your monthly copay.
    • Best for: employers looking to find an affordable prescription drug plan for their employees.

    OptumRx (formerly Prescription Solutions)

    OptumRx is a healthcare management company that offers pharmacy benefit management solutions to organizations across the healthcare industry. Their pharmacy solutions include home delivery services, member engagement, pharmacy management and specialty pharmacy management.

    Citizens Rx

    Citizens Rx is a full-service pharmacy benefit management provider operating in over 10 major cities across the United States. It provides services such as specialty and mail-order pharmacy, claims processing, formulary management and custom implementation services for each client.

    • Formulary management: Citizens Rx encourages generic substitution programs without compromising quality, access or clinical oversight. Its formulary suggestions are reviewed by clinical experts to make sure alternative drug choices are appropriate before financial considerations are made.
    • Rebate management: In need of rebate administration services? Citizens Rx gives you timely, streamlined rebate management services for group or individual health plans. It identifies the methodology used to calculate and assign payments from drug manufacturers and then honestly negotiates on your behalf.
    • Mail and specialty service: Citizen Rx currently provides specialty pharmacy services in Los Angeles and Tampa Bay, Florida. It also offers mail-order service in Tampa Bay.
    • Mobile Rx: Citizens Rx has a smartphone app called Pharm-Assist (get it?) that acts as a virtual pharmacy card for each member. It also provides dosage reminders, nearest pharmacy locations, refill alerts and 24/7 access to help resources.
    • Accreditation: Citizens Rx is newly accredited by URAC for pharmacy benefit management. Its current accreditation is valid through June of 2019.
    • Best for: employers who don’t want to include mail-order or specialty pharmacy in their drug benefits.

    Prime Therapeutics

    Prime Therapeutics focuses on getting people the medicine they need at the best price possible. Through its services and solutions it helps control drug costs, emphasizes integrated management with specialty pharmacy services and exceeds the industry’s compliance and quality standards.

    • Health plan solutions: Prime Therapeutics works directly with health plans to provide what's needed. It helps bring medical and pharmacy benefits together to efficiently manage pharmacy costs. Prime Therapeutics continually refines its pharmacy network, formularies and benefit designs to help fight price inflation.
    • Medicaid solutions: Prime Therapeutics has more than 10 years of experience working with Medicaid. It knows about each state’s regulatory needs and works with clients through a state-by-state approach. It helps you design a Medicaid pharmacy program that works best for your members.
    • Medicare solutions: Prime Therapeutics’ Medicare programs and processes align with Centers for Medicare and Medicaid Services (CMS) requirements. It improves Medicare plan savings with formularies that include discounted, low-cost drugs while still maintaining quality and meeting CMS requirements.
    • Employer solutions: Prime Therapeutics’ model connects employers with the needs of their employees. Employees get 24/7 customer service to resolve any issues that may come up. Prime boasts the lowest ingredient costs for more than six years in a row (nearly $6 less than competitors). It also helps employees with specialty pharmacy needs adhere to their therapy and prescription drug regimen.
    • Accreditation: Prime Therapeutics is accredited by URAC for pharmacy benefit management and mail service pharmacy. It’s also on the Verified Internet Pharmacy Practice Sites (VIPPS) accredited pharmacy list.
    • Best for: health plan providers and employers wanting customizable pharmacy solutions.

    11 – 11 Best Rated Pharmacy Benefit Management

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    Prime Therapeutics is a pharmacy benefit management company based in Eagan, Minnesota. It offers solutions to help health plan providers and employers offer affordable prescription drug plans to their employees.