PBM 101
PBMs typically incentivize enrollees to use this by offering 90-day rather than 30 day prescription fills with a discounted co-pay compared to the 30 day fill.
What is Mail Order?
This is typically consistent across the same chemical, dosage form and strength and is applied to generics as well as certain multi-source brand drugs.
What is MAC pricing?
This allows members to benefit by paying lower copay on the 25% of the generic drugs that fall int he lowest tier.
What is Generic Tiering?
In this type of network, consumers' copayments and out-of-pocket costs are identical regardless of which pharmacy in the retail network dispenses the prescription.
What is an Open pharmacy network?
This is a program that mandates members to utilize our Specialty pharmacy for their specialty medications.
What is Exclusive Specialty Pharmacy?
What is May 1, 2019?
This is determined by the lowest of AWP discount, MAC price or U&C.
What is Ingredient Cost?
This is a list of drugs that are covered by the plan, along with the member's co-pay for each covered drug and any restrictions on use.
What is a formulary?
This includes CVS, Walmart and Target and are major pharmacy chains anchoring our level one pharmacies.
What is Rx Choice Tiered Network?
This model will determine the Paid PMPM impact when changing from the National formulary to Preferred and/or Essential formularies.
What is the Formulary Steerage Model?
WAC x Units x Discounts = this
What are Rebates?
These are arrangements that charge the client the same price the pharmacy is paid for each drug.
What is Transparent/Pass-thru pricing?
By doing this with Specialty Drugs a group can achieve the most cost effective therapy.
What is splitting specialty drugs into Preferred & Non-Preferred tiers?
This is an educational program describing the benefits of home delivery through member communications.
What is Home Delivery Education?
This model provides the prospective savings a client may see when switching to the Rx Choice Network as well as member disruption.
What is the Rx Choice Tiered Network Model?
These are generally multi-state employer groups primarily headquartered in an Anthem, Inc. service area with 5,000 or more eligible employees, of which at least 5% are located outside o the headquarter state.
What are National Accounts?
What is the Single Source Generic (SSG) optic?
This formulary option is for clients whose key priority is pharmacy cost control and rebate revenue opportunity.
What is the National Formulary?
This program allows a member to opt to receive a 90-day supply of maintenance drugs at a retail pharmacy.
What is Retail90 Network?
This model will show the impact to a client's plan if they were to move to the Preventative Rx plan design from what they currently have.
What is the Preventive Rx Model?
Berkshire Hathaway
JP Morgan Chase
Amazon
PillPack
What are the new peripheral players in the industry?
These arrangements create margin opportunities between the rates paid to the pharmacy and the rates charged to the client.
What are Traditional/Margin/Spread pricing?
This is a pharmacy benefit design that combines a generics-based formulary with select bran-name medications.
What is Generic Premium?
This provides members the ability to op-out of "mandatory mail" plan design by calling in to customer service.
This is for client who have concerns about the accessibility of our pharmacy network.
What is the Geo Access Modeling for Rx Choice Network?