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Pharmacy Benefit Managers (PBMs)

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

EnvisionRx (Covered drug lists)

EnvisionRxplus


Future Scripts


OptumRx

Phone: 1-800-711-4555

Fax: 1-800-527-0531

Prior authorization appeals: 1-888-403-3398

OptumRx website-for professionals

OptumRx Drug Formulary


Prime therapeutics


Silverscript


Copyright 2016, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.

Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other laypersons, or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.

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