Straightforward Process, Results That Matter

Our human-led, independent clinical utilization management uniquely positions us to deliver strategic savings. Clients who contract with us for utilization management save an average of $17-$28 more per-member-per-month (PMPM) compared to plans managed by traditional pharmacy benefits managers (PBMs) 

Our pharmacy benefits optimizer (PBO) model is 100% client-aligned. We are not beholden to a single PBM or offering. We maintain an innovative marketplace where traditional and transparent PBM solutions compete for our clients’ business. We advocate for our clients so they can optimize their pharmacy benefits while taking excellent care of their members. Our clients see an average 7:1 return on investment – $7 in clinical savings for every dollar they spend on our clinical management solutions. These are hard dollar savings. 

Here’s how we do it: 

• We begin by analyzing current plan economics, including utilization patterns and drug mix, to help clients choose the right solutions including formulary and plan design.  
• Our independent clinical utilization management helps clients achieve strategic savings. Traditional PBMs use an automated prior authorization (PA) process, which may let inappropriate prescriptions get approved. Our PA reviews are conducted by independent pharmacists with a focus on ensuring patients receive the most appropriate, cost-effective medications. When they see a prescription for a high-cost brand drug that does not deliver any incremental clinical benefit, they replace it with clinically equivalent, lower-cost alternatives, thus saving the plan money while maintaining member access and care. Our clinical utilization management catches off-label, inappropriate, or potentially unsafe PA requests more than 20% of the time – far more often than the average 10% flagged in our PBM counterparts’ automated processes.  
• Our hands-on intervention program is designed to optimize medication regimens for members with complex conditions or comorbidities who may be taking either multiple drugs or need a closer review of details like dose appropriateness, therapy duplication, and potential drug interactions. Our pharmacists work collaboratively with providers, including condition specialists or licensed medical doctors and utilize a peer-review process to improve clinical efficacy while reducing plan costs. 

At RxBenefits, strategic savings and sustainable success are not just words, they are part of our core values and the guiding force that powers our mission of ensuring that every working American and their employer has access to quality prescription medications at an affordable cost.