Administrative Services

RxAdvance’s Collaborative PBM Cloud™ offers an unmatched suite of proven PBM administrative services. All services can be configured to meet each plan sponsor specific needs with enhanced flexibility enabling plan sponsors to customize its service model. Only RxAdvance brings together the industry’s best and most sophisticated, collaborative, and unified enterprise platform to provide real healthcare value, cost control and efficiency. RxAdvance provides its expertise to every plan sponsor to generate value-driven pharmacy benefit management closing care gaps and improving outcomes. RxAdvance has a network of over 67,000 pharmacies that includes both retail and specialty pharmacy providers throughout the country. RxAdvance has highly competitive rebate contracts with all pharmaceutical companies.

RxAdvance offers following administrative services:

Benefit Plan Design and Modeling Services

Compared to a plan sponsor’s medical benefit structure, a typical PBM’s pharmacy benefit structure is simplistic and lacks a variety of key characteristics. PBMs’ inability to leverage medical diagnosis data within their benefit design structure creates a cumbersome authorization process that may potentially incur avoidable medical spend. In order to manage a cost-effective benefit structure, RxAdvance believes this module should be able to facilitate prospective cost and quality modeling for better financial/clinical outcomes.

Collaborative PBM Cloud™ enables a completely integrated array of granular and flexible benefit design solutions. This holistic approach to benefit design leverages a single integrated data model that is highly configurable in real-time, employing collaborative modules to simplify and streamline the process of designing and implementing a variety of complex benefit design scenarios. This module also enables benefit design compliance.

RxAdvance believes that cost-effective and high-quality pharmacy product deployment requires that plan sponsor actuarial staff are able to easily access and analyze a pharmacy benefit structure and associated formulary. In other words, to compete effectively in the market, plan sponsors should be able to simulate cost modeling using historical utilization data. Upon approval by plan sponsors, the implementation of the pharmacy benefit through RxAdvance is a seamless process that requires minimal manual intervention.

Ongoing maintenance, customization, and integration of the benefit design to align with patients’ needs, cost issues, medical benefit designs, and other dynamic requirements are all streamlined through RxAdvance’s Collaborative PBM Cloud™ framework. Complete and dynamic modeling enables all plan stakeholders to see the impact of proposed changes, thereby creating a more robust decision-making process.

Additional features of this module include:

Model drug coverage strategies that leverage a library of more than 300 custom benefit designs for commercial and employer health group plans

Format a variety of deductible and out-of-pocket cost criteria to craft innovative benefit structures

Fully compliant benefit structures for Medicare, exchanges, and MMPs (Medicare-Medicaid Plans)

  • Custom benefit structures based on pharmacy networks, formulary, tiers, days’ supply, and drug types
  • Support for benefit programs such as RRA (Retail Refill Allowance), mandatory generic program, first fill limit, member pay difference, and copay incentive programs
  • Easy configuration of CMS copay requirements for various benefit stages and LIS
  • Design and implementation of various point of sale/point of care processes to achieve optimal clinical and financial outcomes

Formulary Management Services

When it comes to formulary management, which encompasses a high complexity of interdependent variables, PBMs should leverage both Artificial Intelligence (AI) algorithm-driven benefit/formulary design and collaborative plan sponsor engagement. An AI-driven solution is required due to the magnitude of decision variables in the following areas:

  • Membership mix
  • Benefit design
  • New generic offerings — prospective
  • Drug utilization patterns
  • Rebate contract complexity
  • Multiple lines of business
  • P&T committee medication efficacy recommendations
  • Ingredient cost variations

This AI solution should also includes:

  1. A dynamic computational modeling capability that considers all clinical and relevant financial variables
  2. A system-generated gap analysis highlighting differences between the optimal and existing formularies
  3. An ability to “accept/deny” at a line-item level system-recommended formulary changes
  4. A system-generated multi-year transition action plan and corresponding formulary
  5. Member and prescriber engagement tools for adoption based on habitual member and prescriber utilization patterns to derive an ideal formulary with optimal financial (lowest net cost) and clinical outcomes for plan sponsors

AdvanceFormulary leverages this “first-in-market” AI capability that is built into Collaborative PBM Cloud™ with modules such as AdvanceClaims, AdvanceSpecialty, AdvanceAnalytics, AdvancePNC, and AdvanceRebate. These services employ a unified data model to analyze both retrospective (e.g., historical claims data) and prospective (e.g., generics replacing brands) data to create a system-derived optimal formulary that results in superior clinical and financial outcomes for the plan sponsor.

AdvanceFormulary™ also provides a system-generated gap analysis enabling RxAdvance and plan sponsor staff to work collaboratively to analyze the gap between the system-derived optimal formulary and existing formulary to identify clinical and financial variances. Using these system-driven gaps as a foundation, both RxAdvance and the plan sponsor can conduct iterative dynamic modeling to develop a practical multi-year transition action plan. This transition action plan includes engaging providers at point of care and proactive member engagement through IntelligentDUR360°Gateway to enable the seamless adoption of formulary adjustments.

Recognizing that plan sponsors have unique formulary needs that require customization to meet specific goals, RxAdvance provides clients with modeling and impact analytics to derive the most efficient and cost-effective standard and specialty formularies. Formulary compliance is promoted through RxAdvance’s Collaborative PBM Cloud platform using extensive edits and alerts at point of care and point of sale, by proactive member engagement and leveraging the seamless integration with clearinghouses. RxAdvance will work with the Pharmacy and Therapeutics (P&T) committee to recommend new or revised utilization protocols throughout the year providing formulary utilization visibility to plan sponsors.

Additional AdvanceFormulary™ include:

  • Management and design of a variety of formularies for Commercial, Medicare Part D, Medicaid, and Exchanges with a highly customizable and intuitive platform
  • Support for multiple third-party drug databases, classification systems, and drug attributes to build and manage a formulary
  • Configuration of drug lists, drug tiers, and utilization management rules (PA, ST, and QL) for single or multiple formularies
  • Comprehensive and streamlined formulary change management process for quick decision making and turnaround time, supported by the fully integrated Collaborative PBM Cloud™ platform
  • Powerful analytics to analyze drug utilization trends, UM edits, and plan-to-plan comparisons
  • Built-in CMS rules, guidelines, and RxCUI crosswalk to seamlessly generate formulary and UM files
  • Customization and dynamic generation of compliant forms: PA, ST, member and provider notices, and drug lists

Pharmacy Network Contracting Services

Compared to a plan sponsor’s provider contracts, a PBM’s pharmacy network contracts are rudimentary and lack a variety of key characteristics: the granularity required to manage pharmacy payments effectively in real-time; the ability to incorporate performance-based quality/cost measurements; the ability to create an effective “mosaic” network that is completely aligned with plan sponsor membership needs; and incentive-based prospective and retrospective clinical services at Point of Sale.

AdvancePNC is a granular, multi-level configurable, and fully integrated module within AdvanceClaims. AdvancePNC delivers cost management, quality improvement, oversight, and incentive alignment features. This module also facilitates prospective cost and quality modeling for better financial/clinical outcomes enabling RxAdvance pharmacy network contracts to be on par with the plan sponsor’s provider contracts.

AdvancePNC Services include:

  • National network of over 67,000 pharmacies that includes independents, chains, and specialty pharmacies
  • Leveraging additional messaging space on standard NCPDP D.O transactions to communicate actionable information to pharmacies, making the interaction with pharmacies software agnostic
  • The promotion of preferred contracting using quality and cost indices
  • Intelligence and guidance to maximize the impact of desktop/onsite audits
  • The ability to create “mosaic” networks (sub networks) to optimize better quality/cost outcomes
  • Real-time FW&A alerts
  • System-driven streamlined contracting and credentialing process
  • Real-time modeling of actual paid amounts vs. plan sponsor contract guaranteed amounts

Claims Processing Services

In the marketplace, a conventional belief is that claims processing is a commoditized and low value-added services. In spite of spending significant time and money on legacy claims engines, potential business value is not achieved by the current PBMs. These dated engines have fragmented and inflexible subsystems with multiple incompatible data models — and they need to be replaced. At RxAdvance, we believe claims processing is a core transactional service that has significant potential to be transformed into a high-value and low-cost service.

AdvanceClaims delivers this needed transformation to plan sponsors

Low-cost and high-value service is achieved through AdvanceClaims, an integral component of Collaborative PBM Cloud™, which was built from the ground up using state-of-the-art technology that is highly flexible, scalable, and automated, and that provides and ajudication of specialty and non-specialty claims. This adjudication engine offers unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules.

Fully integrated system of record for eligibility, membership, prescribers, pharmacy network contracts, pricing, benefits, formularies, authorizations, and compliance rules enabling seamless claims adjudication

Rapid implementation is accomplished through user configurability that leads to dramatic improvement in timeliness, cost, and accuracy

Fully integrated and highly flexible Formulary Management Services (AdvanceFormulary), a core component of AdvanceClaims. Highly customizable to a payer’s membership and line of business. Facilitates proactive formulary modeling to optimize clinical and financial outcomes

At Point of Care when an eligibility/benefit/authorization /formulary request is generated, IntelligentDUR360°Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the physician’s workflow as a single message

At Point of Sale when pharmacy claims are submitted for adjudication, IntelligentDUR360°Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the pharmacist’s workflow as a single message

Proactive member engagement is initiated when patient-specific quality/cost information is generated in Collaborative PBM Cloud™ and is then delivered to the member’s smart mobile device using IntelligentDUR360°Gateway™

Clinical/pharmacy staff of plan sponsor are engaged collaboratively through Patient-Rx360°™ to reduce pharmacy costs and drug-impacted medical costs, and improve health outcomes

Analytical and Reporting Services

Plan sponsors continue to be frustrated with PBMs’ inability to provide timely data, analytics, reporting, and visibility for effectively managing pharmacy and medical risk. It is extremely important to fully integrate PBM-generated and plan sponsor-generated data to understand and influence standard and specialty drug spend, medical spend, compliance, business needs, and financial forecasting, and to effectively manage administrative and medical risk. Currently, no PBM is delivering comprehensive and patient-specific actionable information real-time to prescribers, pharmacists, members, and clinical/pharmacy staff of payer to create better health outcomes. Dynamic modeling capabilities are also absent in the current PBM service offerings.

AdvanceAnalytics, leveraging Collaborative PBM Cloud, provides plan sponsor executives with real-time visibility and ad hoc reporting capability:

Executive Visibility

OperationalPricingCost and quality

AdvanceAnalytics, leveraging Collaborative PBM Cloud™, delivers over 300 standard real-time reports integrating PBM and plan sponsor data in the following categories:

Report Categories

Executive dashboardClaims processingDirect and indirect remuneration (DIR)
e-prescribingPharmacy network auditPrescription drug event (PDE)
Rebate managementPatient and prescriber profilingFinancial management
Clinical managementUtilization managementPrior authorization
PharmaciesMedicare Part DService Level Agreement (SLA)

AdvanceAnalytics, leveraging Collaborative PBM Cloud™, delivers the following analytics, enabling plan sponsors to effectively manage pharmacy and medical risk:


Prescribing patternsP4P modeling – pharmacistsFraud, waste, and abuse analytics
Cost/quality indexP4P modeling – prescribersMember cost analytics
Dispensing patternsPA modelingBenefits modeling
Utilization analyticsMTM modelingFormulary modeling

AdvanceAnalytics, leveraging Collaborative PBM Cloud™, delivers actionable information to prescribers, pharmacists, members, and clinical/pharmacy staff of payer into their respective workflows to create better health outcomes:

Point of Care / Point of Sale / Proactive Member Engagement Alerts

Generic substitutionMedication adherenceDrug-age precautions
Clinical abuse and misuseStar RatingsDrug-gender precautions
High or low dosagesInappropriate duration of drug treatmentDrug-pregnancy precautions
Cost savingsDrug allergiesCoverage Gap Prescription Prediction & Planning Services
Over and under utilizationDrug-drug interactions
Therapeutic appropriatenessDrug-disease interactions

Rebate Management and Modeling Services

By design, rebate management services provided by large PBMs are not seamlessly transparent to a level that enables plan sponsors to make effective decisions. Typical financial processes used in business decisions such as formulary and benefit design, new product launching, budgeting and forecasting, and predictive modeling are not provided by PBMs’ rebate tools. This effectively causes plan sponsors to miss out on a significant savings opportunity.

AdvanceRebate changes this paradigm by providing a seamless, information-rich, and predictable cost savings solution. Using artificial intelligence algorithms, AdvanceRebate, leveraging Collaborative PBM Cloud, derives an optimal formulary/benefit design that takes into consideration all the products/plans and their respective utilization, P&T committee therapeutic recommendations, plan-paid amount, and member-paid amount. RxAdvance has over 150 competitively negotiated rebate contracts with all pharmaceutical companies across all lines of business.

Designed with health plan staff in mind, AdvanceRebate includes the following sub modules:

  • Rebate contract management
  • Rebate setup/configuration
  • Rebate modeling, data analytics, and forecasting
  • Automatic rebate invoicing generation
  • Dynamic rebate reporting
  • Streamlined reconciliation

The AdvanceRebate™ Services include:

  1. Competitive rebate contracts for all manufacturers inclusive of supplemental rebate contracts
  2. An integrated, comprehensive, and flexible rebate management platform that enables contract setup and maintenance with minimal personnel support
  3. A dynamic contract-modeling tool to aid renegotiation with manufacturers, allowing the simulation of ‘what if’ scenarios to prepare and respond to contractual opportunities
  4. Instantaneous/easy-to-model formulary changes, which effectively support the P&T committee process with potential rebate impacts of proposed changes
  5. Full and transparent access to all rebate results, for all stakeholders
  6. Real-time performance of rebate contracts based on preset thresholds to determine planned to actual results

Enterprise Service Manager

The current business model of PBMs involves providing only limited administrative/clinical services, forcing plan sponsors to outsource various critical functions to multiple vendors. As a result, vital information for critical decision-making is dispersed across disconnected and inflexible vendor subsystems, making it impossible to obtain a comprehensive, 360° view for the care stakeholder at the Point of Service.

RxAdvance’s unique value proposition to the plan sponsor is to provide comprehensive drug benefit management services without outsourcing a single critical function. These comprehensive services are offered through Collaborative PBM Cloud™, which is built on a unified data model. As an overlay on Collaborative PBM Cloud™, AdvanceESM™ (Enterprise Service Manager) extracts and consolidates information across all departments of the PBM, providing plan sponsors with a 360° view enhancing critical health/financial decision-making resulting in best outcomes.

AdvanceESM empowers customer services representatives (CSRs):

  • When a prescriber requests services from a CSR, comprehensive information comprising eligibility,
    benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FW&A index, and MTM are provided via Patient-Rx360°™. In addition, AdvanceESM™ promotes effective prescribing and utilization patterns through P4P programs
  • When a pharmacist requests services from a CSR, comprehensive information comprising eligibility,
    benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FW&A index, MTM, claims and financial reconciliation are provided via Patient-Rx360°™. In addition, AdvanceESM™ promotes effective dispensing and utilization patterns through P4P programs
  • When a patient requests services from a CSR, comprehensive information comprising eligibility,
    benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage
    gap and prescription planning, cost saving opportunities, adherence, and MTM are provided via
    Patient-Rx360°™. In addition, AdvanceESM™ enables the CSR to educate the member to optimize
    their prescriber and pharmacist consultations

AdvanceESM empowers plan sponsor staff:

  • By pushing comprehensive patient information — eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, cost saving opportunities, adherence, and MTM information through IntelligentDUR360°Gateway™ into customer service, case and care management, and utilization management workflows for effective member engagement and best health/cost outcomes
  • By providing unprecedented operational visibility to conduct PBM oversight functions, such as monitoring contractual obligations and service level agreements (SLAs), with full insight into compliance and regulatory requirements/performance
  • With an integrated and comprehensive view of the utilization of drug benefits by prescriber, pharmacist, and member, enabling alignment of respective incentives:
    » Prescriber — optimize contracts through targeted P4P programs
    » Pharmacist — modify pharmacy network contracts for best quality/cost outcomes
    » Member — adjust the benefit design and out-of-pocket costs

These incentive recalibrations will enable the plan sponsor to effectively manage overall administrative/medical risk