Pharmacy Benefit Risk Management

How We Do It

US-Rx Care goes far beyond traditional Pharmacy Benefit Administration models, by actually engaging in the management of pharmacy risk for our clients. Our methods not only produce sustainable cost reductions typically in the range of 10%-35% per member per month, but plan beneficiaries (members and dependents) typically enjoy out-of-pocket savings of 30% or more as well.

US-Rx Care’s approach to prescription drug fulfillment and benefit management represents a significant departure from methods and practices typically employed in the marketplace for the past twenty years. Our success in driving down prescription drug costs is achieved through active management of the pharmacy benefit, including the following key elements:

US-Rx Care’s proprietary clinical management approach is one key to our exceptional client savings beyond anything any other PBM service provider has been able to achieve. US-Rx Care proprietary Right Rx Platform incorporates over 1,000 proprietary rules and algorithms directly into the claims review process, to identify opportunities for quality and cost improvement.  When a rule/algorithm is triggered, a cascade of provider and/or patient communications follows to encourage utilization of alternative (more cost effective) options obtained from the lowest cost source.  Dramatic and sustainable cost savings are routine along with high member satisfaction.

The US-Rx Care team has over 20 years of experience managing specialty pharmaceuticals for some of the nation’s largest health insurers.  Our clients benefit from unbiased, expert review of every case, to ensure that any high cost medication is medically necessary, cost effective, and conforming with national guidelines and current standards of care.  US-Rx Care clients have enjoyed reductions in annual specialty pharmacy spend by 20% or more for specialty medications.

US-Rx Care utilizes one of the most sophisticated and flexible, high-capacity pharmacy benefit management systems in the industry for benefit set-up and pharmacy claims administration across a comprehensive network of over 62,000 participating pharmacies, including multiple competing specialty pharmacies, in real-time.

US-Rx Care has complete freedom and flexibility to customize formularies, deductibles and coinsurance, and clinical programming to effectively and actively manage the pharmacy benefit.