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Why Carve-out?

Reduce benefit costs and provide budget stability


Most Rx plans are carved-out to a Pharmacy Benefit Manager (PBM)

Pharmacy Benefit Managers administer prescription drug benefit programs for more than 215 million Americans who have health insurance from a variety of sponsors.


Most Medical Insurance Carriers carve-out to a PBM

Most Medical Carriers outsource the administration of their prescription drug plans to PBMs, acknowledging that using a true expert in this critical area of health care makes sense.

 Medical Carrier

 Subcontracted PBM



 Highmark Blue Cross Blue Shield

 Express Scripts

 Horizon Blue Cross Blue Shield

 Prime Therapeutics, LLC (Prime)

 Independence Blue Cross Blue Shield



 Express Scripts


Medical Carriers insured prescription drug programs cost more

Under a carved-in benefit your prescription drug claims are normally marked up, also known as spread pricing, causing higher claims costs.  It is expected that, come 2015, up to 67% of an employer’s total prescription drug spend will come from specialty medications.  With this rise in specialty drug costs, which can average $1,776 per prescription (compared to a $54 average per standard drug); it is best to protect your company’s wallet by working with a specialist that focuses solely on the pharmacy benefit.


Fixed-rate insured Rx programs lower costs and provide budget stability

  • Pass-through pricing at retail – 100% of retail pharmacy discounts = lower claims costs
  • Acquisition cost pricing at mail and specialty – Customized specialty care plus pass-through acquisition cost pricing lower claims costs
  • Expert Rx management through ongoing clinical review for patient safety and cost savings
  • Real time medical and prescription data integration – No other PBM or carrier can integrate medical and prescription claims data prospectively to identify previously invisible conflicts and prevent the development of adverse events


Isn’t it time to speak to an Rx Specialist?



Last Updated Saturday, September 21, 2019 - 08:51 PM.