In the United States, payment for prescription medications is handled not by the health insurance but by the “Pharmacy Benefit Manager.” Sometimes the health insurance acts as its own pharmacy benefit manager, but frequently pharmacy benefits are delegated to another company, the pharmacy benefit manager.
Why does this matter to us?
If either the prescribing clinician or the patient/family member want to know what medications are on the formulary for their health insurance, they need to go to the website for the pharmacy benefit manager and not the website for the health insurance. Also, since there are a few big players among the pharmacy benefit managers, if we become familiar with the formulary for 2-3 of the biggest ones, this will cover a high proportion of our patients.
How can I find out who my patients’ pharmacy benefit manager is?
On the patient’s health insurance card, the pharmacy benefit manager will be listed as well. If no separate pharmacy benefit manager is listed, it may mean that the health plan manages its own pharmacy benefits.
Note: The pharmacy benefit manager need not be the same for all health plans offered by a particular health insurance company.
Here is an alphabetical list of some of the pharmacy benefit managers in the US along with links to their websites. By going to their websites, prescribing clinicians can get up-to-date formulary information and other information.
EnvisionRx (Covered drug lists)
Prior authorization appeals: 1-888-403-3398
OptumRx website-for professionals
OptumRx Drug Formulary
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