A transparent Pharmacy Benefit Manager (PBM) or Pharmacy Benefit Administrator (PBA) operates with full disclosure of costs, fees, and rebates associated with prescription drug benefits. Unlike traditional models, we provide clear and detailed reporting on drug pricing, rebates, and administrative fees, ensuring that our clients and members understand precisely how their pharmacy benefits are managed and the associated costs.

Yes. We partner with a broad national network of pharmacies to ensure members have access to affordable medications. Our price transparency tools allow members to compare costs and find the most cost-effective options, including generics and therapeutic alternatives.

A formulary is a list of prescription drugs covered by a pharmacy benefit plan. It’s designed to balance clinical effectiveness, safety, and cost, prioritizing medications that provide the best value for members. Our formularies are developed transparently, with input from clinical experts, to offer the most appropriate medicines at the best possible cost, along with clear rationales for covered drugs.

A brand drug is developed and patented by a pharmaceutical company and sold under a specific name. A generic medicine contains the same active ingredients, strength, and dosage as the brand, but is typically more affordable after the brand’s patent has expired. We promote generics when clinically appropriate to lower costs for clients and members.

Prior authorization is a process requiring approval from the PBM or plan before certain medications are covered. It ensures that the prescribed drug is medically necessary and appropriate for the patient’s condition. We streamline PA processes to minimize delays while maintaining transparency about criteria and decisions.

Step therapy is a program that requires members to try lower-cost or preferred medications before moving to more expensive options. This approach ensures cost-effective care without compromising quality. We clearly communicate step therapy protocols to members and providers.

Specialty drugs are high-cost medications used to treat complex or rare conditions, such as cancer or rheumatoid arthritis. They often require special handling, administration, or monitoring.

A pharmacy network is a group of pharmacies contracted with a PBM to provide prescription services to members. Our extensive network comprises over 67,000 pharmacies nationwide, ensuring convenient access to medications.

Drug tiers categorize medications based on cost and coverage levels in a formulary. As tiers go up, they may have a higher copay.

Copay: A fixed amount members pay for a prescription (e.g., $10 for a generic).

Coinsurance: A percentage of the drug cost members pay (e.g., 20% of a brand drug’s cost).

Deductible: The amount members pay out-of-pocket before the plan covers costs.
We provide clear explanations of these costs to members to aid decision-making.

Retail pharmacies are local stores where members fill prescriptions in person. Mail-order pharmacies deliver medications directly to members, often providing 90-day supplies of maintenance drugs, which offers convenience and potential cost savings. We provide transparent pricing for both options.

A drug utilization review is a process to evaluate prescription patterns for safety and appropriateness, checking for issues like drug interactions or overutilization. Our DUR processes are designed to protect member safety while maintaining transparency with clients.