A pharmacy benefit manager (PBM) processes prescription drug claims on behalf of you and your plan sponsor (usually your employer). In order to provide this service, we contract and negotiate with retail pharmacies and pharmaceutical manufacturers to provide the right balance of drug access and cost-effectiveness.
Because we’re advocates for you and offer more plan insight to your employer. Did you know that with other prescription drug plans, your copay for a drug could be higher than the price of the drug without any insurance at all?
We give you more choice and control over your care. Think of us like a personal shopper for your prescriptions. We check out all of your options for brand name and generic drugs. Then, we share the information with you in real time, so you can make an informed choice. We’ll also let you know about any additional savings, like discounts or coupons.
Some medications are covered under the pharmacy benefit, while some are covered under the medical benefit and others are covered under both benefits. Typically, medications that are injected or infused are covered under the medical benefit. These are administered at a doctor’s office, an infusion center or at home. Typically, medications that are self-administered are covered under the pharmacy benefit. Log in to the AffirmedRx Member Portal app or website, or check your plan materials, to learn more about how your plan covers medications.
To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand medications because they have lower-cost, covered alternatives which are used to treat the same condition. Meaning, the alternative works the same or similar to the non-covered medication. If you’re taking a medication that your plan doesn’t cover and your doctor feels an alternative is not right for you, he or she can ask AffirmedRx to consider approving coverage. If you don’t get approval and you continue to fill a non-covered medication, you’ll pay its full cost out of pocket directly to the pharmacy and the cost can’t be applied to your annual deductible or out-of-pocket maximum. Your plan may also exclude certain medications or products from coverage. This is known as a “plan (or benefit) exclusion.” For example, your plan may exclude medications that aren’t approved by the U.S. Food and Drug Administration (FDA).
Your plan excludes certain types of medications or products from coverage. This is known as a “plan (or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the drug class or to treat the specific condition. There is also no option to receive coverage through a medication review process.
Ask your doctor’s office to contact AffirmedRx so we can start the coverage review process. They know how the review process works and will take care of everything for you. AffirmedRx will review information your doctor provides to make sure you meet coverage guidelines for the medication. AffirmedRx will let you and your doctor know within 72 hours of the decision. If you meet the coverage guidelines, you’ll be approved for coverage of the medication. If you don’t meet the coverage guidelines, you and your doctor can appeal the decision. We’ll send you information either way.
The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over-the-counter products) may be available to you at no cost-share ($0), depending on your plan. Log in to the AffirmedRx Member Portal app or website, or check your plan materials, to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list with this link.
Yes, you can access a copy of your AffirmedRx ID card on the AffirmedRx Member Portal app or website.
A generic medication is the same as the brand name medication in safety, effectiveness, quality, strength and dosage, as well as in the way it’s taken and used. Brand name medications are protected by patents. Patents prevent other manufacturers from selling generic versions of the brand name medication. Once a patent ends, other companies can make and sell a generic version of the brand name medication. Generics are typically sold under their chemical or scientific name, instead of the manufacturer’s patented brand name.
Yes. A generic medication works in the same way and provides the same clinical benefit as its brand name version. Generic and brand name medications have the same:
Yes. The U.S. Food and Drug Administration (FDA) requires that a generic medication work in the same way and provide the same clinical benefit as its brand name version. This means that generics must:
You can typically save money with generics. Generic medications typically cost 85% less than the brand name medication.
Generic manufacturers don’t have to repeat the expensive clinical trials that were required of the brand name medication. Also, there’s usually more than one company making a generic version of a brand name medication, which creates more competition in the marketplace and helps lower the generic’s price.
You can email our clinical experts anytime at Help@affirmedRx.com to discuss what cost-savings opportunities are available for you. We can give you this information and work directly with your doctor to get a new prescription if a change in therapy is appropriate.
You can find your price of any medication at specific pharmacies across the nation through the AffirmedRx Member Portal app or website. If you have technical questions about the AffirmedRx Member Portal app or website, please call (888) 211-1608 or email Help@affirmedRx.com. You may also call (888) 460-1579 anytime to speak to an Account Services representative about medication prices for your plan.
Copay assistance programs help reduce your copay for prescription drugs. They can include discount cards, coupons or programs you enroll in through the manufacturer.
You usually need to provide your name, address, date of birth and the drug name. You may also need to provide some financial information. Program sites will list terms and conditions for participating. You should carefully review these terms and conditions to understand how your information will be used and the limits the program may have.
Copay assistance programs usually have a website or phone number to call. You can also look up your drug’s name and manufacturer on the internet to find drug-specific programs. We may be able to help you enroll, but you will need to read the terms and conditions on your own. Some programs may provide you with a card or account number to use.
Programs are not usually covered under health care privacy rules because they are not health plans or providers. They may have to follow consumer protection or state rules on privacy or data breach. This information and any commitments to handle your information confidentially will be listed in their terms and conditions.
Restrictions can vary by program. Most copay assistance cannot be used for drugs that you are paying for with government health insurance such as Medicare, Medicaid or Tricare.
Many programs last up to one year with the possibility for renewal, although some programs may last longer. Some programs may also have a maximum allowed dollar limit.
This tool tracks your copays, coinsurance, out-of-pocket maximum and certain benefits (e.g. , day limits on certain benefits). The accumulators reset each year.
A claim review step that compares claims to covered services on a plan and determines the amount of payment, if any, for that claim. Also called Adjustment.
The Affordable Care Act (ACA) is a law which created rules and guidelines for health care coverage. It was signed by President Obama in 2010. The ACA changed how many people buy and pay for health insurance. For example, it requires many employers to offer certain health benefits.
This is important if you have a family plan. This is a health plan that covers you, as well as other dependents. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An aggregate deductible means the family has to meet the deductible before your plan helps pay for care for any of you. Plans may vary, but the costs you pay for covered care and services usually go toward meeting this deductible. Most plans call this a "family deductible."
A formal process where a member and/or provider requests that a decision about medical necessity is revisited and potentially changed.
A term used to refer to the services covered by your health insurance. AffirmedRx manages your “pharmacy benefit” for your employer, your health plan or your plan sponsor.
The total amount the plan sponsor or employer will pay on the pharmacy benefit. It is usually within a given timeframe. For example, a plan sponsor or employer may pay up to $10,000 per member over one year for prescription drugs. If the cost of the prescription drugs reaches $10,000 within a year, the member is responsible for 100% of the cost of all prescriptions for the rest of the year.
A fixed percentage of the cost of each prescription that the member needs to pay. Coinsurance can be applied to all drugs or certain types of drugs. For example, a member pays 30% of the cost of a brand drug.
Medicine with different ingredients combined together in order to tailor it for individual needs. Once mixed together, compound drugs are not FDA-approved.
If you are covered by two or more health plans, this process decides the amount each plan pays for a claim.
A fixed dollar amount for each prescription that is paid by the member. The copayment may vary according to the type of drug. For example, $10 brand/$6 generic copayments.
A provision of the pharmacy benefit that requires you to pay some portion of the cost of the product or service. Examples of cost-sharing include copayments and deductibles.
The member pays the whole cost of each prescription, up to a specified dollar amount. Once that dollar amount is reached, the prescription drug benefit takes effect. For example, a member may be required to pay 100% of all prescription costs up to $1,000. After that, the member only pays a coinsurance of 25% when he or she fills a prescription.
Covered drugs that are covered by the pharmacy benefit plan.
A process done by AffirmedRx where a member’s prescription drug use is looked at to find situations where we can improve the member's health and drug costs.
This is important if you have a family plan. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An embedded deductible means your health plan will begin covering you as soon as you meet your deductible, even if the family deductible has not been met.
This is a drug that is not listed on the formulary. The drug is not available at a reduced copayment or coinsurance amount under normal conditions.
If your health plan does not cover a service, your provider may file an appeal. At that point, the decision may go to external review. In an external review a third-party will review the claim and appeal. The third-party is someone not connected to you or your health plan. Both you and your health plan must accept the third-party decision.
This is important if you have a family plan. This is a health plan that covers you, as well as other dependents. Your deductible is what you need to pay for care before your health plan starts to help pay for care. A family deductible means the family has to meet the deductible before your plan helps pay for care for any of you. The costs you pay for covered care and services goes toward meeting this deductible.
An account set up through your employer that you can use to pay for certain out-of-pocket medical costs with tax-free dollars. You decide how much money to put in your FSA, up to a limit set by your employer. Your employer also can put money in the account. You don't pay taxes on this money. You can use your FSA to pay for health care costs, such as insurance copays and deductibles.
The US government agency that enforces the laws on the manufacturing, testing and use of drugs and medical devices.
A list of prescription medications covered by your prescription/pharmacy benefit plan. If a medication is not on the formulary, it isn’t covered under your plan and you’ll have to pay the entire cost; it may also be called a drug list.
Medications that can be made by more than one manufacturer because the patent has expired; Generics have the same active ingredients as brand medications and are approved by the U.S. Food and Drug Administration (FDA); Generics are often the lowest-cost medication option.
An account offered by employers that provides tax-free reimbursement for qualified medical costs up to a fixed dollar amount each year. In many HRA plans, you can roll over your unused amounts from the current year to use in the next year. You might also hear HRAs called Health (or Health care) Reimbursement Arrangements.
This law, which took effect on April 14, 2003, was the first-ever federal privacy standards act to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers. HIPAA was developed by the Department of Health and Human Services as the new standards to provide patients with access to their medical records and allow them greater control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. HIPAA includes provisions designed to encourage electronic transactions and also requires new safeguards to protect the security and confidentiality of health information. The final regulation covers health plans, health care clearinghouses and specific health care providers who conduct certain financial and administrative transactions (e.g. , enrollment, billing and eligibility verification) electronically.
A savings account you can set up if you have a high-deductible health plan. An HSA lets you set aside pre-tax money to pay for certain medical costs, such as deductibles, copayments and coinsurance. You can roll over your unused balance into the next year and change how much you contribute to the account at any point during the year.
Type of benefit plan that requires you to pay toward a deductible before the plan starts covering expenses. Typically, HDHPs offer lower monthly premiums to offset the higher deductible.
This is important if you have a family plan. Your deductible is what you need to pay for care before your health plan starts to help pay for care. An individual deductible means your health plan will begin covering you as soon as you meet your deductible, even if the family deductible has not been met.
These medications are only available at specific pharmacies in the United States and are used to treat conditions that are extremely hard to manage. These medications require special handling, patient support and monitoring.
Our Mail Order Pharmacy partners serve members nationwide and dispense medications from multiple facilities throughout the United States to ensure the fastest delivery possible.
This is a program where members have to use generic drug products when available. Members who choose to use the brand product rather than the generic drug product have to pay a higher copayment, a greater coinsurance amount or the full price of the drug.
The most your plan will cover for medications or services during the plan year
The amount a member must pay for a drug product is determined by what “tier” the medication has been placed into. Multi-tier benefit plans generally have between two and five tiers.
A fixed dollar limit on a member’s out-of-pocket expenses. After reaching the limit, drugs can be filled at a lower cost or at zero cost to the member. The amount owed depends on the member’s benefit structure. All drugs or only certain types of prescriptions a member receives may go toward the out-of-pocket maximum. For example, all copayments/coinsurance may be applied to an out-of-pocket maximum of $200 for an individual and $400 for a family. Once the person or family pays a total of $200 or $400 for prescriptions, all new prescriptions are dispensed at zero cost to the member.
Drugs which may be purchased without a prescription. They are not covered under most prescription/pharmacy benefit plans.
The Patient Protection and Affordable Care Act (PPACA) is a law which created rules and guidelines for health care coverage. It was signed by President Obama in 2010. The PPACA changed how people buy and pay for health insurance. For example, it requires employers to offer certain health benefits.
A pharmacy benefit manager (PBM) is an administrator of a prescription drug program. A PBM is primarily responsible for processing and paying prescription drug claims. Technically, PBMs are private firms that contract with employers, insurers and public and private plan sponsors, but HMOs, managed care organizations, state governments, etc. also can function as PBMs.
Benefit plan or design determines what drugs the plan does and does not cover, in what quantities, from what pharmacies and other drug sources, and at what out-of-pocket cost to members.
A group of pharmacies with which a PBM contracts to provide pharmacy services to its members.
In some drug classes, there are multiple medications that treat the same condition or symptoms – to help control costs, the plan may designate certain medications as preferred. Preferred medications are typically a lower-cost option than non-preferred.
The amount you pay for your health insurance coverage, either in a lump sum or through installments.
The written instruction for medicine that a licensed medical professional provides. The abbreviation for prescription is Rx.
This is a type of medicine. It must have a doctor's prescription before it can be sold. It is different than an over-the-counter drug that can be bought without a prescription.
The process where specified drugs on the formulary require extra review by clinical staff before they are covered by the benefit plan.
The maximum amount of a medicine a health plan covers during a certain period of time. These limits are set for safety reasons and to help reduce costs. If your doctor prescribes more medicine than your plan allows, the doctor will have to contact the plan to approve the amount.
One of the criteria screened during your health plan's prescription vendor's real-time point-of-sale edit process, refill-to-soon measures the percentage of a prescription which must be used before the prescription can be refilled. This assures that medications are not dispensed too frequently.
Your pharmacy benefit may include coverage for certain products that are referred to as specialty medications. These specialty medications are prescribed to treat certain conditions, such as anemia, cancer, cystic fibrosis, growth hormone deficiency, hepatitis C, multiple sclerosis and respiratory syncytial virus. Most specialty medications are injectables or require special shipping and handling, such as refrigeration. As a result, distribution of specialty medications and additional related services are arranged by a specialty provider.
A process designed to help control high medicine costs. If your plan applies step therapy to your prescription, it will require that you try a lower-cost medicine that’s proven effective to treat your condition before it will cover a higher-cost medicine. If the lower-cost medicine does not treat your condition effectively, your plan’s coverage will “step” you to a higher-cost medicine to find a medicine that treats your condition effectively at the lowest possible cost.