Pharmacy Benefits Management (PBM)

Personalize a pharmaceutical benefit plan and get the information you need for better care.

Pharmacy Benefits Management (PBM)

Improve the prescription benefits within your pharmacy benefit management arrangement.

Spend less and know more with Phoenix PBM. Even the most complicated benefit plans can be simple to understand and easy to manage. We work with you to define goals and benchmarks and to audit your current services. With the relationship and information in place, we’ll tailor a solution that can flex to meet your changing needs. And you’ll always know how your plan is performing thanks to clear, in-depth reporting tools.

Account Management Services

An attentive, knowledgeable Phoenix PBM account manager is your single point of contact for all of your questions, problems, concerns, and opportunities. We meet with you on a quarterly basis to discuss enhancements to your pharmacy benefits program and provide report utilization, spend, patient adherence, performance guarantees, quarterly pipeline reporting, specialty pharmacy trends.

Benefit Plan Design and Management

Whether you need to reduce costs or maximize rebates, Phoenix will help you design the prescription benefit plan that meets your specific needs. Customized logic and edits support all types of copays, coordination of benefits and subrogation, and point of service messaging. Get real-time access to eligibility options for swift plan design and implementation.

Customize the formulary that matches your population requirements and needs – including Medicare and Medicaid:

  • "Closed"/ Generic-only Formulary: Designed for value. Formulary drugs include most generics and select branded medications, and cover a specific set of drugs in each drug class.
  • "Open" Formulary: These are brand name and generic drugs that are covered under your prescription drug benefit and offer the greatest overall value. Open formularies may extend the benefits of a prescription plan but may increase overall pharmacy costs.
  • "Restricted" Formulary: Designed to provide value. This option covers specific drugs including most generics and selected brand medications in each drug class.

Medications classified as non-formulary are not generally covered under the benefit. Non-formulary medications must meet medical necessity criteria through an exception process to be covered under a prescription benefit.

Claims Administration

Real flexibility is the ability to select the exact prescription benefit program or plan design you need, no matter how straightforward or complex your needs might be. Phoenix PBM processes more than 150 million claims annually because we fully customize each pharmacy benefit solution and consistently upgrade each one to address changes in the marketplace, including capacity.

Consumer and Pharmacy Call Center

Phoenix PBM representatives can enter your overrides, prior authorizations, and direct member reimbursements. You can reach our toll-free pharmacy and customer service department during extended business hours:

Monday through Friday: 8:00 am and 10:00 pm EST
Saturday and Sunday: 10:00 am to 6:00 pm EST

The Phoenix PBM claims operation system is available 24/7/365.

Drug Utilization Review

Take comfort in knowing you have access to safe, effective lower cost medications. Phoenix will help you improve medication adherence, educate your members, and even provide clinical services in-house if needed.

Phoenix clinical services include: Concurrent Drug Utilization Review, Retrospective Drug Utilization Review, and Coverage Authorizations (Prior Authorization, Step Therapy, etc.)

Pharmacy Claims Auditing

Improve your oversight of pharmacy claims within the Phoenix PBM pharmacy network and know that your claims satisfy plan criteria as well as federal and state requirements.

Pharmacy Network Management

The Phoenix network is 61,000 pharmacies strong, including independents, regional and national chains. Select the Phoenix Pharmacy Network, Phoenix Preferred Network, or Phoenix Exclusive Network based on the complexity of your PBM needs.

  • Phoenix Pharmacy Network: An open network of more than 61,000 participating pharmacies, including major pharmacy chain, big box pharmacies, regional chain pharmacies, and most independent pharmacies.
  • Phoenix Preferred Network: A limited network of approximately 42,000 participating pharmacies, including one major pharmacy chain, some big box pharmacies, regional chain pharmacies, and some independent pharmacies.
  • Phoenix Exclusive Network: A client-specific network that includes one major pharmacy chain, a big-box pharmacy chain, a grocery store chain, and independent pharmacies to fill coverage gaps. The average size of a Phoenix Exclusive Network is between 20 to 12,000 pharmacies, determined by which pharmacy chains and other pharmacies you need.

Phoenix clients also have access to Mail Order and Specialty Pharmacy Services through fully integrated strategic partnerships.

  • APOGEE Bio-Pharm, LLC is our mail service vendor partner. Each prescription they dispense is subject to the same utilization review edits as the network retail pharmacies.
  • BioPlus provides the ability to dispense specialty prescription drugs. Each prescription they dispense is subject to the same utilization review edits as the network retail pharmacies and mail order pharmacy.

We record all service claims in our claims processing system for clear reporting. All brand prescriptions dispensed from their facility are eligible for formulary rebates.

Reporting Services

Phoenix PBM Express is a powerful web-based management reporting/decision support system. Get timely, dynamic, and secure clinical financial reporting and protect your proprietary claims data within a secure web environment. Here's how it works:

  • The system captures data every day from the Phoenix adjudication engine and loads it into the PBM Express Oracle database to provide ready, secure access to clinical and financial information.
  • Choose from a suite of predefined, standardized reports as well as the option to create ad hoc, customized reports.
  • Generate reports by the date the claim was processed or by the date the prescription was dispensed.
  • Simplify analysis by grouping comprehensive data by rank. The user-friendly web interface exposes key cost drivers to inform the cost-minimization strategies.
Specialty Drug Copay and Pharmacy Assistance Programs

Save money and have happier, healthier, more engaged employees. Phoenix PBM can help you get your Rx spend under control, improve member medication non-adherence, and raise the sustainability of your pharmacy benefits program. Our advocates will work closely with you to design a plan and submit paperwork to help you recognize manufacturer assistance, $0 Rx Copay for certain specialty meds, and up to 80% in employer savings.

Phoenix provides access to the fundamental resources that help people live healthier lives.

We have excelled in this effort for decades by providing bigger savings, more options, better resources, and the best customer service in the business.

Better Savings

The Phoenix System is a static transaction-based fee structure that is simple to understand provides access to the greatest possible benefits for brokers, agents, TPAs, organizations and patients.

More Options

Phoenix PBM clients have the prescription benefits they need at the fairest price. We review financial, plan design, eligibility, and rebate details with you to verify that you're getting the greatest value from every element in your plan.

Better Resources

Better information is at the center of better health. The Phoenix dashboard puts your accounts, options, and statistics like user demographics, claims reports, and brand name and generic use reports at your fingertips.

Peerless Customer Service

Customer service excellence lives at our core. When you call, we answer. When you have a question, we have a thoughtful answer. Our team is pharmacy trained, bilingual, and committed to meeting your specific prescription benefit needs.

Why Phoenix

With Phoenix, brokers, TPAs, labor unions, and consumers benefit from scalable, low-cost individualized prescription benefit plans and the very best customer responsiveness and care.

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Corporate Overview

Learn how Phoenix is simplifying complex healthcare solutions and creating successful, affordable prescription benefits programs for our clients and their customers.

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Questions? Let’s talk.

Phoenix is a committed, responsive partner who listens first and works hard to address your needs so we can succeed together. How can we help you?

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