Pharmacy Benefit Manager Resources
To help your clients better manage their pharmacy benefits, we provide them with 24/7, online, secure access to an array of tools and resources.
Your clients may log in or register to access the following tools and resources:
With access to their pharmacy information, you and your clients are better able to manage everything from plan design to formulary management and control overall costs. Here you will find reports detailing their company’s prescription drug utilization, trends and more.
Current Brokers: Log in to our online reporting tool
RxView provides Employers, Plan Sponsors and Brokers with access to members' demographic and prescription benefit information. It allows access to member eligibility, claims history for filled prescriptions and the ability to view prior authorizations.
Current Brokers: Log in to our RxView tool
Our Prescription Drug Formularies are updated often. Your clients will have access to the latest formulary for their plan benefit.
Optimize your pharmacy benefit with PBDRx's breaking updates, in-depth insights, and thought leadership.
Glossary of Terms
Understand key pharmacy benefit and prescription drug terms with clear, plain‑language definitions designed to help you navigate your coverage with confidence.
A request for your plan to review a decision or a grievance again.
RA biosimilar is a biological product that is highly similar to an already FDA-approved biologic, known as the reference product. While made with living organisms and not identical to the original drug, a biosimilar has no clinically meaningful differences in terms of safety, purity, and effectiveness. Biosimilars must meet rigorous FDA standards to be approved.
Medications sold under a proprietary, trademarked name by the manufacturer. These drugs are approved by the FDA and undergo extensive testing for safety and effectiveness. The manufacturer typically holds exclusive marketing rights for a set period, during which time generic versions can't be marketed.
Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The plan pays the rest of the allowed amount.
A request for a benefit made by you or your provider to your plan for items or services you think are covered.
The process of evaluating a prescription drug claim that is typically sent by a pharmacy. This includes checking your eligibility, determining coverage and reimbursement, calculating copays, reviewing for utilization management requirements (like quantity limits or prior authorization), and ensuring the prescription isn’t filled too soon. This ensures that claims are processed quickly, accurately, and according to plan design.
A fixed amount (for example, $15) you pay for a covered prescription or service, usually when you receive the service. The amount can vary by type.
The amount you owe for prescriptions or services your plan covers before your plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered prescriptions or services subject to the deductible. The deductible may not apply to all prescriptions or services.
The drugs listed below are what is covered under your plan when prescribed and obtained according to plan guidelines. Note, some drugs require you (and your doctor) to get prior authorization or require step therapy.
- Self-Funded: Drugs Covered (Formularies)
- Medicare: Drugs Covered (Formularies)
The categorization of prescription drugs on how much they cost within a particular drug benefit plan. Typically, higher drug tiers will have higher copays. Factors such as generic vs brand, preferred vs non-preferred, and traditional vs specialty can impact a drug's tier placement.
A review process used to evaluate whether a medication therapy is appropriate, medically necessary, and safe. DURs can happen before, during, or after a prescription is filled. They help flag issues like drug interactions, incorrect dosages, allergies, and other potential risks to ensure optimal patient outcomes.
A list of drugs your plan covers. A formulary may include how much your share of the cost is for each drug. Your plan may put drugs in different cost sharing levels or tiers. For example, a formulary may include generic drug and brand name drug tiers and different cost sharing amounts will apply to each tier.
Drugs that are chemically identical to their branded counterparts but generally have lower prices. Generics are reviewed and approved by the FDA and feature the same safety, efficacy, quality, benefits, strength, and dosing as their brand-counterpart.
In-network refers to the network of providers that participate with your plan. If you choose to access services in network, you will receive your plan’s negotiated rates with those providers.
A pharmacy service that offers the convenience of mailing prescriptions directly to your mailing address.
The facilities, providers, and suppliers your plan has contracted with to provide prescriptions or services.
If you use a non-participating facility, provider, or supplier, your prescription or service is subject to your deductible, plus any copayment and/or coinsurance and balance billing.
A benefit your employer, union, or other group sponsor provides to you to pay for your prescriptions or services.
A decision by your plan that a prescription or service is medically necessary. Sometimes called preauthorization, prior approval or precertification. Your plan may require preauthorization for certain prescriptions or services before you receive them, except in an emergency. Prior authorization isn’t a promise your plan will cover the cost.
Drugs and medications that by law require a prescription.
A physician, healthcare professional, or healthcare facility licensed, certified, or accredited as required by state law.
A type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a healthcare professional, or is relatively difficult to dispense. Generally, specialty drugs are the most expensive drugs on a formulary.
A type of utilization management that requires you to try one or more lower-cost or safer medications first - often generics or preferred alternatives - before coverage is approved for a more expensive or higher-risk option. If the initial therapy is ineffective or fails, the next step in treatment may be covered.
A designation that two drugs are expected to have no clinical difference in efficacy and safety when administered to patients under the same conditions.