Full PBM Model or Utilization Management Only? Choosing the Best Pharmacy Benefits Option

Jun 10, 2024

Building a high-value benefits plan is crucial for self-insured employers to control costs while improving employee satisfaction. However, this is easier said than done on the pharmacy side of healthcare benefits, as prescription drug costs continue to rise in response to a myriad of factors, including inflationary pressures, utilization, and, most notably, the conflicted PBM relationship characterized by hidden profits at the expense of plan sponsors and enrollees.1

Employers who self-sponsor their health plans take a front seat in their pharmacy benefit plan decisions, but selecting the right solution can be challenging due to binding contract terms and a lack of transparency from PBMs. That’s why clinical pharmacy organizations like US-Rx Care provide more than one option, allowing employers to choose the solution that best fits their needs while providing the highest value possible — whether it’s full pharmacy benefits management or behind-the-scenes utilization management.

Piece-Meal or Full-Service: Evaluating Pharmacy Benefits Solutions

Selecting the right pharmacy benefits solution depends on a number of factors, including existing vendor relationships, financial considerations, and overall goals for your pharmacy plan. Self-insured employers can select one of these two solutions:

  • Pharmacy benefits management. The full PBM model encompasses every service that touches the pharmacy benefit, including formulary management, claims processing, pharmacy network management, medication management, and specialty pharmacy services. This comprehensive approach provides an all-in-one solution to help employers streamline pharmacy benefits administration by keeping all prescription drug information in one place.
  • Utilization management. Instead of an all-inclusive solution, employers can leverage utilization management to establish a stronger clinical backbone within their existing PBM relationship. This solution focuses entirely on reviewing prescription drug claims through a clinical lens, with a team of healthcare professionals working to ensure members receive the best possible medication at the lowest available price. By targeting utilization patterns and promoting cost-effective prescribing practices, this solution aims to control pharmacy costs while ensuring appropriate medication utilization.

Maximize Savings and Satisfaction With a Fiduciary Partner

Despite best appearances, a PBM or utilization management organization will fail to provide optimal savings if they do not contractually adhere to fiduciary responsibilities — the same standards that self-insured employers are required to follow. A fiduciary partner like US-Rx Care can fundamentally transform an employer’s pharmacy benefit plan, leveraging a PBM or utilization management solution to unlock higher value and deliver maximum savings for both the plan and its enrollees.

The core difference between traditional and fiduciary PBMs is the ultimate goal of their efforts. Where traditional PBMs notoriously seek opportunities for profit, a fiduciary only works in the plan’s best interest, operating with full price transparency and eliminating every conflict of interest. By removing hidden profits from the equation, fiduciaries can negotiate lower prices, optimize formularies to only include the appropriate medications, and implement cost-saving strategies tailored to each employer’s plan needs.

Choose the PBM That Works For, Not Against, Your Plan

As a leader in the fiduciary PBM space, US-Rx Care has the clinical and pharmacy benefit administration expertise necessary to sharply cut the costs of needed prescription drugs. Our full PBM solution is proven to save up to 50% on pharmacy benefit costs in just 12 months for self-insured employers. Alternatively, employers who wish to keep their PBMs can carve out utilization management and prior authorization functions to our clinically-based Right Rx program. By advocating strictly for your enrollee’s best interest, Right Rx saves an average of $15-$25 per enrollee per month with over 30% or greater out-of-pocket savings for non-specialty, specialty, and J-code prescription drugs. Whether your organization is looking for partial or full pharmacy optimization, US-Rx Care has the tools and cost-saving frameworks in place to deliver the savings and plan value your enrollees deserve.

Learn more about US-Rx Care’s pharmacy benefit services to discover which solution is best for your plan.


  1. Wager, E., Telesford, I., Cox, C., Amin, K. (2023, September 15). What are the recent and forecasted trends in prescription drug spending? Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/recent-forecasted-trends-prescription-drug-spending/#Annual%20change%20in%20per%20capita%20retail%20prescription%20drug%20spending,%201970%20-%202021;%20projected%202022%20-%202031%C2%A0