Pharmacy Benefit Management

What is Pharmacy Benefit Management?

Pharmacy benefit management encompasses a variety of services required to quickly and accurately process prescription claims for a variety of recipients covered by a variety of plans offering a prescription benefit (insurance, Medicaid, Medicare, Worker’s Compensation, etc.). PBMs are most commonly responsible to set up plan specific Rx benefit parameters, and then adjudicate and handle the pharmacy network and plan billing/payments. In recent years, with the explosion of new and costly drugs and particularly specialty drugs in the market, many PBMs also offer clinical programs and case management services meant to help control costs to the plans/payers. 

PBMs also offer lists of “preferred” prescription drugs that are partially or wholly discounted by an organization’s prescription drug benefit plan, known as a Formulary; the PBMs contract with a network of participating pharmacies, and negotiate price reductions and rebates between their client’s organizations and drug companies.  

Because of complex business and revenue strategies, the relatively small number of PBMs in the market, and the fiercely competitive industry landscape; pricing manipulations and incremental upcharges that are very hard to track, often result in the steady but unnecessary increase of pharmacy benefit costs. 

Crystal Clear Rx is a pharmacy benefit management consulting group whose priority is to provide support, deliver information and find savings opportunities for payers who are looking to understand more about how their Rx benefit is being managed and in turn, save money on their total drug spend. This often requires outside support in the management of their PBM. We will review existing PBM contract agreements, raw claims data, pricing and payments and report our findings to help you sort out your options. Crystal Clear Rx will help you determine which action(s) are in your best interest: 

  • Conduct a thorough pharmacy benefit management audit.
  • Regularly monitor you’re your PBM’s performance.
  • Propose contractual adjustments to protect against overspend. 
  • Look for a new PBM. 

We are singularly focused on your best interest and will help you get the maximum value from your PBM contract. Unlike many of our competitors, Crystal Clear Rx does not accept kickbacks, rebates, or profit-sharing of any kind from any PBM, PBM consulting group, or Big Pharma. 

Our focus is on deriving value from existing Rx benefit plans. Our PBM monitoring and audit system will identify very specific and actionable areas of opportunity where your benefit spend could be optimized. Many PBMs reap the rewards by taking advantage of industry complexities and actually may prevent you from saving money. We support you, inform you and save you money by effectively managing your PBM. 

Contact us for a free consultation to get started.