Integrated Full-Service Pharmacy Benefit Management

Comprehensive Service Offerings



nirvanaspecialty services

RxAdvance offers nirvanaRxCloud™, a national full-service pharmacy benefit management (PBM) solution that leverages the Collaborative PBM Cloud™ platform to manage standard and specialty drug benefits with unmatched regulatory compliance and transparency. These comprehensive PBM services comprise of Administrative Services, Clinical Services, and Value-Add Services.

Administrative Services

RxAdvance’s nirvanaRxCloud™ offers an unmatched suite of proven PBM administrative services. All services can be configured to meet each plan sponsor’s specific needs with enhanced flexibility enabling customization of 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.

RxAdvance’s 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 plan sponsor actuarial staff to be 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 becomes 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 and Modeling 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 Services

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

Prior Authorization Services

Prior authorizations (PA) too often frustrate and impede quality care, while adding 20 hours per week to the
administrative burden of medical practices and costing the healthcare system a staggering $69 billion annually.
Current stand-alone PA software systems, because they are isolated and unable to integrate medical, pharmacy
and lab data, lack a comprehensive view of the patient. They also fragment workflows and make it hard to keep
up with changing state and federal regulations.

By leveraging pharmacy, medical, and lab claims data, AdvancePA™ delivers automated PA decision-making and
clinical pathways to prescribers. It is an integral part of the claims processing system, is rule-based and is easily
configurable. Options for configuration extend beyond patients’ clinical and medical needs to include optional
prescriber metrics such as prescriber utilization, quality and cost indices, and prescribing patterns. This enables
further automation and additional reductions in abuse and misuse.

The comprehensive workflow capabilities of AdvancePA™ connect and support everyone engaged in a patient’s
care — prescriber, nurse practitioners, medical directors, pharmacy technicians, and pharmacy directors.
Communication with prescribers, pharmacists and patients integrates versatilely and seamlessly with
electronic prior authorization (ePA), voice, email, fax, web, and mobile cloud interfaces. AdvancePA™,
AdvanceClaims™ and AdvanceFormulary™ share data, rulesets and workflows, decreasing errors and
increasing process efficiencies.

Drug driven rule sets and inbuilt machine learning enable AdvancePA™ disease specific algorithms to limit
pharmacy staff requirements. They also ensure ultimate consistency among reviewers as well as system driven
compliance, resulting in lower plan sponsor administrative fees. In addition, AdvancePA™ reduces unnecessary
administrative burdens for medical practices. In turn, AdvancePA™ reduces unnecessary physician offices’
administrative burden, streamlining PAs, resulting in provider contracting leverage for plan sponsors.

Member Mobile Cloud Services

Forty-five percent of the US population suffers from one or more chronic conditions, requiring long-term maintenance medication. It is a well-established fact in the industry that approximately half of these chronic patients are nonadherent to their complex medication regimens. AdvanceMobile™ integrates all demographic, medical, pharmacy, and lab data to derive a 360° view of the member opportunities surrounding cost and quality. The personalized health coach provided by AdvanceMobile™ drives constant engagement through gamification, allowing the app to more meaningfully influence consumer behavior. This disease-driven mobile platform encourages members to make intelligent health and well-being decisions, leading to unparalleled member cost reduction and quality improvement. In addition, the 360° member view provided by AdvanceMobile™ will allow plan sponsors to replace all existing member apps, for a single comprehensive and configurable platform across all membership.

Personalized Health Dashboard

All available health information is integrated toprovide a personalized dashboard of current health conditions and associated medications. Users can also toggle to see a personal list of all actionable alerts, highlighting opportunities for out-of-pocket cost reduction, quality improvement, adverse drug event reduction, and adherence improvement. Attention to and completion of these alerts is encouraged through rewards and gamification.

My Medical Conditions and Medications

The homepage lists all member-specific medical conditions. Clicking on a condition will display all associated prescriptions with a corresponding personal adherence score.

My Reminders

Member-specific reminders include physician visits, medication reminders, and vital recordings reminders.

Disease-Driven Drug Information

Drug-specific cost savings, quality improvement, and adherence improvement alerts include:

  • Cost Savings Alerts
  • Generic Substitutions
  • High-Risk Alerts
  • Drug-Drug/Disease/Age/Gender Interactions
  • Duplicate Therapies
  • Medication Adherence Alerts

My Rewards

Gamification empowers engagement. Members earn points by completing achievable health goals and bonus missions defined through their specific medical conditions, medications, weight, age, and gender. They are consistently engaged for the opportunity to redeem points in exchange for plan sponsor-defined rewards. Through engagement, this rewards program encourages the development of long-term healthy habits. Additional features include multi-layer rewards schedules, leaderboards, and achievement based badges. Motivate members to collect them all!

Insurance Information

Member access tools include:

  • Historic claims
  • Drug and procedure cost estimator
  • Tiers and copay information
  • Prior authorizations
  • Explanation of benefits
  • Donut hole prediction & prescription planning


Clinical Services

RxAdvance’s staff of experienced pharmacists and care managers provide plan sponsors with clinically-driven services focused on safety, efficacy, and cost containment. Using Collaborative PBM Cloud™, RxAdvance plan sponsors will receive value-added clinical analyses, reporting, and recommendations that will improve clinical outcomes while controlling costs.

Our innovative and distinctive clinical services include:

Medication Therapy Management (MTM) Services

Due to PBMs’ inability to conduct impactful MTM services, plan sponsors are forced to outsource MTM to vendors whose tools are labor-intensive, semi-automated, and standalone. As a result of this ineffective outsourcing, plan sponsor staff, pharmacists, and prescribers are unable to work collaboratively to produce low-cost and high-quality MTM outcomes.

To address these critical deficiencies, AdvanceMTM through IntelligentDUR360°Gateway™ delivers a fully integrated MTM solution

  • Fully configurable with automated patient identification, enrollment, and notification that processes in real-time and alerts prescriber at the Point of Care
  • Every time a prescriber prescribes a new medication, AdvanceMTM™ dynamically analyzes a range of factors, including cost, prescriptions, diseases, additionally configured criteria, and newly prescribed medication to determine the MTM eligibility of the patient. If the patient is MTM eligible, AdvanceMTM™ alerts the prescriber to complete the comprehensive medication review (CMR)
  • The CMR is pre-populated with prescription history, which streamlines the workflow for the prescriber,enabling easy entry of OTC and non-PBM recorded medications
  • The Patient-Rx360°™ prescription listing is then overlaid against patient medical claims and disease conditions, populating the following alerts:
Generic substitution Therapeutic appropriateness
Inappropriate duration of drug treatment Medication adherence
Clinical abuse and misuse Drug-disease interactions
High or low dosages Drug-drug interactions
Over and under utilization CMR
Drug-gender precautions Drug allergies
Drug-pregnancy precautions Drug-age precautions
  • A new Patient Medication Listing (PML) and a Medication Action Plan (MAP) is automatically generated for patient consultation
  • After successful CMR, a compensation payment is queued up automatically pending patient confirmation of CMR completion through smart mobile device. This CMR process is completed in less than 15 minutes

Pharmacy-Integrated Total Care Services

Forty-five to fifty percent of the overall US population has at least one chronic condition, and one in four Americans have multiple chronic conditions. This population utilizes approximately 86% of the total US healthcare spend. While pharmacotherapeutic research has produced many novel therapies to reduce the disease burden of chronic conditions, many patients are still unable to control their illness due to prescription and care plan non-adherence.

At RxAdvance, we believe that engaging and motivating this population to take charge of their health early in their diagnosis will reduce avoidable medical costs significantly. Technology lies at the heart of RxAdvance’s solution. Smartphones, machine learning, and connected devices are reshaping the way people interact with the world, and these same technologies should reshape healthcare. From a patient perspective, these technologies need to be convenient, interactive, and reducing costs while improving care experience. RxAdvance’s Collaborative PBM Cloud™ delivers targeted actionable intelligence at all nodes of the care continuum, while continuing to support, educate, and engage patients as a companion in their health journey.

“PBMs have a unique opportunity to improve the quality of care, reduce the cost of care, and impact adherence due to their integral part in the transaction cycle from the Point-of-Care to the Point-of-Sale.”

RxAdvance harnesses this opportunity through the following approach:
1. Care-Level Identification: When a member receives an initial diagnosis of a chronic condition, RxAdvance’s platform analyzes the members’ medical, pharmacy, and lab information to assign the member to an appropriate care level. RxAdvance offers a three-tiered solution to address the specific needs of chronic care members. Each tiered solution increases in complexity based upon the level of care required by individual members in the corresponding risk band.

1• Single existing or recently diagnosed chronic condition in early stages of disease cycle• Mobile enabled member engagement
• Incentive driven disease management
2• Multiple chronic conditions
• Rising risk of complications and/or rapid progression of disease
• Complex medication regimen
• Need for objective adherence data for disease management
• Mobile-enabled member engagement
• Incentive-driven disease management
• Simplified medication delivery with disposable pill tray
3• Multiple chronic conditions with complications
• Multiple ER visits and hospitalizations due to chronic conditions
• Multiple identified gaps in care or high-risk medications requiring close monitoring and early intervention
• Mobile-enabled member engagement
• Incentive-driven disease management
• Simplified medication delivery with disposable pill tray
• Recommended: Full nirvanaAccountableCare™ services

2. Enrollment and Onboarding: Once the member is classified into an appropriate care level, prescribers and pharmacists are alerted to review the member’s prescription plan. At the Point-of-Care during a refill/new prescription, the Intelligent DUR360o Gateway™ system alerts prescribers with adherence-related information that prompts a prescriber to conduct a comprehensive medication review (CMR). This system-generated medication review identifies and eliminates medications for which adverse drug events outweigh the benefits and are ineffective for the patient’s overall quality of life. After identifying the optimal prescription regimen, the patient is recommended to a health plan-sponsored total care plan.

3. Mobile-Enabled Member Engagement: Through AdvanceMobile™, members are engaged in an interactive app-driven rewards program. AdvanceMobile’s gamification model provides incentives for completing different health goals, which vary at different steps of the member’s treatment journey. After enrollment, the app will deliver targeted adherence goals and other care plan tasks personalized to the member’s health needs. For eligible members in care level 2, AdvanceTotalCare™ aggregates, organizes, and delivers medications through a disposable pre-filled pill tray.

Ongoing Communication and Dynamic Care Plans: AdvanceTotalCare™ communicates efficiently with all care stakeholders to promote positive adherence to medication and care plans. As the Collaborative PBM Cloud™ receives updated claims and medical data specific to each member, care plans are updated to respond efficiently to new information. Any member-specific quality of care measures identified by the plan sponsor are also communicated to the members. Members are encouraged to report medication adherence and vital recordings through the AdvanceMobile™ app, and are given rewards for positive engagement and healthy behaviours.

Coverage Gap Prediction & Prescription Planning (CGP3) Services

It is the PBM’s responsibility to predict which patients are approaching the coverage gap and proactively work with plan sponsors, prescribers, and patients to build an effective and alternative prescription plan to mitigate the impact of the benefit gap.

To address this critical need in the market, RxAdvance launched AdvanceCGP³™, a solution that facilitates dynamic coverage gap determination modeling and offers a prescription planning capability.

  • IntelligentDUR 360°Gateway™ automatically generates a list of patients who will approach the coverage gap by using prior-year pharmacy claims data and patient-specific disease conditions
  • Post identification, the system generates a therapeutic alternative path that eliminates/extends the coverage gap and proactively encourages members to engage the prescriber
  • During the subsequent patient visit with the physician, IntelligentDUR 360°Gateway™ alerts the physician about coverage gap alternatives available to the patient and enables the physician to select an alternative prescription regimen to mitigate the impact of the coverage gap and increase adherence
  • IntelligentDUR 360°Gateway™ proactively informs clinical/pharmacy staff of RxAdvance and plan sponsor about patients and prescribers who are ignoring coverage gap system alerts and generates outreach communication alerts
  • IntelligentDUR 360°Gateway™ also notifies clinical/pharmacy staff of plan sponsor about patients who have traditionally been adherent and who will stop taking medication due to their coverage gap even after adopting a suggested alternative path. This empowers the plan sponsors to compare medical costs due to non-adherence with coverage gap medication costs and thus allows plan sponsors to make more thoughtful business decisions geared toward creating better health outcomes

Specialty Management Services

RxAdvance’s “Authorize & Manage” is an end-to-end 8 step process, supported by the Collaborative PBM Cloud™RxAdvance Specialty Management Services include: 

  1. Specialty Formulary Management: RxAdvance leverages both “first-in-market” artificial intelligence (AI) capabilities and collaborative plan sponsor engagement to deliver a system-derived optimal specialty formulary that results in superior clinical and financial outcomes for the plan sponsor and members. AdvanceFormulary™ is a highly customizable and intuitive platform, embodying the capabilities to provide gap analysis to identify areas of clinical and financial improvement; to support multiple third-party drug databases and classification systems; to configure drug lists, tiers, and utilization management rules; to streamline formulary change management processes for efficient decision-making and implementation; to analyze drug utilization trends; and to harness built-in CMS rules and guidelines.
  2. Specialty Prior Authorization (PA) Management: RxAdvance delivers a collaborative, rule-based, and user-configurable PA system that leverages all data sources. This enables determination of clinical/medical necessity, prescriber utilization, and prescribing patterns through AdvancePA™ and AdvanceFormulary™.
  3. Specialty Utilization Management: The system ensures that requested drugs meet P&T protocols (quantity limits, route of administration, and place of administration) by leveraging industry guidelines/ADE indications and therein delivers this information at Point of Care and Point of Sale through Intelligent DUR360° Gateway™.
  4. Specialty Procurement/ Distribution Management: RxAdvance facilitates the acquisition of specialty drugs from the preferred specialty pharmacy network. These preferred specialty pharmacies are offered best-in-market pricing by leveraging the RxGalaxy (a wholly owned subsidiary of RxAdvance) wholesaler relationship.
  5. Specialty (Pharmacy Portion of Medical Claim + Pharmacy) Claims Processing: Through AdvanceClaims™, RxAdvance delivers core claims processing transactional services as a high-value and low-cost service. Built from the ground up, this highly flexible, scalable, and automated system provides adjudication of specialty (pharmacy portion of medical claim + pharmacy) claims while offering unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules. RxAdvance’s fully integrated system of record allows for the derivation of actionable intelligence, which can be delivered at the point of care, point of sale, to members through our mobile application, and to the plan’s clinical and pharmacy staff.
  6. Specialty Case Management: The system leverages Patient-Rx360°™ delivered through Intelligent DUR360° Gateway™ to create a concise and coherent case action plan for all stakeholders involved in the well-being of the patient. Coupled with dynamic alerts, the operational 360° dashboard view empowers case managers to prioritize their outreach actions and enables members to receive optimal care from prescribers and pharmacists.
  7. Specialty Concurrent Review Management: RxAdvance automates the process of enrolling targeted members in medication therapy management programs. Information is delivered during the care process by Patient-Rx360°™ to ensure all care professionals are making informed treatment decisions.
  8. Specialty Pharmacy Network Management: Through AdvancePNC™, RxAdvance delivers cost management, quality improvement, oversight, and incentive alignment features. Further, RxAdvance facilitates prospective cost and quality modeling for improved financial and clinical outcomes, enabling RxAdvance Specialty Network contracts to be on par with the plan sponsor’s provider contracts.

Adverse Drug Event Management Services

Preventable medication errors are estimated to impact more than 7 million patients, contribute to 7,000 deaths annually, and cost in excess of $21 billion per year. This fundamental problem is inherent within the current practice of prescribing and dispensing medications without a comprehensive 360° view of patients’ age and gender, disease conditions, medications, and pharmacogenomics data. Conventional PBMs’ inability to aggregate, analyze, and deliver such actionable intelligence to avoid Adverse Drug Events (ADEs) at the point of care, point of sale, and to the patients is largely due to the widespread reliance on outdated, incomplete, and fragmented legacy PBM platforms.

RxAdvance’s three-phase approach to eliminating ADEs

  1. Physician-led CMR: As a first line of defense, RxAdvance will comprehensively assess a new patient’s accumulated drug regimen over a period of time. This review is designed to determine any inappropriate medications and recommend regimen changes to improve disease-conditions and balance this with the patient’s overall quality of life. To optimize the effectiveness of this comprehensive review process, RxAdvance as part of initial implementation, aggregates all patient-specific information (360° view) derived from their historical pharmacy and medical data to correct accumulated retrospective drug inefficacies. All issues and recommendations are immediately sent as alerts to all care stakeholders (prescribers, pharmacists, patients, and clinical/pharmacy staff of payers) through IntelligentDUR360°Gateway™. Patients are prioritized depending upon the level of risk pertaining to their drug inefficacies with corresponding alerts sent to physicians to take appropriate action at the point of care. To support an effective physician/patient consultation, IntelligentDUR360°Gateway™ provides prescribers with a comprehensive view of ADEs and related information, prompting a physician to conduct a comprehensive medication review (CMR). Easy entry of OTC and non-PBM recorded medications is also supported during this process. Using all sources of drugs registered during the patient visit, the system generates a new CMR that identifies and eliminates medications for which adverse drug events outweigh the benefits for the patient’s overall quality of life.
  2. Pharmacogenomics analysis for drug efficacy: After identifying the right prescription regimen, the system automatically generates alerts to the provider to control costs, improve quality, and remove ADEs. Depending on the diagnosis/prescription, the system also prompts the physician to conduct a recommended selective pharmacogenomics analysis. During the follow-up visit, based on results from pharmacogenomics analysis, the drugs that are ineffective are immediately removed or replaced. For example, a recent study has shown that the two most common drugs prescribed to treat Alzheimer’s are effective only 30 percent of the time due to the patient’s genetics. The total annual drug spend for these two medications exceeds $1.5B, resulting in an annual waste exceeding $1.1B due to lack of pharmacogenomics analysis.
  3. Prospective ADE elimination: At the point of care, when the prescriber is prescribing a new drug, the system will validate against the corrected baseline regimen to ensure the new drug added to the patient’s prescription registry is actually improving the patient’s overall quality of life. If a newly prescribed drug exceeds the cost threshold or has individual variability in drug therapy response due to the patient’s genetic makeup, the provider will be directed to go through a prior authorization process to conduct a selective pharmacogenomics analysis to control ineffaceable drug usage.

Value Added Services

Pharmacy benefit managers (PBMs) have a unique opportunity to promote health and generate value in the healthcare system. Today, PBMs are largely evaluated on their ability to control costs rather than improve health. RxAdvance’s unique value proposition comprises of value creation through care stakeholder’s engagement, system-driven compliance management, and standing shoulder-to-shoulder with plan sponsors to take pharmacy risk. This is accomplished through integration of pharmacy, medical, clinical and lab data, stronger partnerships with patients, physicians, pharmacists and clinical/pharmacy staff of health plans, and improved measurement and reporting of results. Incentives for PBMs to promote value should drive innovation and improve health outcomes.

Our Value Added Services include:

Care Stakeholder Services

Effective and efficient care stakeholder engagement for better health outcomes

Prescribers, pharmacists, patients, and clinical/pharmacy staff of payers are frustrated by having to access too many portals and hard copy reports in order to obtain a comprehensive view of a patient’s health, current/past care activities, actionable drug utilization review (DUR) information, comprehensive pharmacy/medical patient profiles, and real-time alerts. The RxAdvance solution to this problem is to deliver actionable information into care stakeholders’ respective workflows at every stage of the care continuum. Putting the right information into the hands of both service providers and members maximizes effective cost management and service excellence.

Comprehensive patient-specific (Patient-Rx360°™) information directly into the workflows of these care stakeholders:

  • To physicians — EMR/PM/e-prescription workflow
  • To pharmacists — pharmacy claims submission workflow
  • To patients — mobile devices
  • To clinical/pharmacy staff of plan sponsors — care/case/disease/UM workflows

Actionable information into care delivery workflows as a single message after instantly extracting, analyzing, and packaging critical information:

  • When an eligibility/authorization/formulary request originates at Point of Care (PoC)
  • When pharmacy claim transaction originates at Point of Sale (PoS)
  • When member-specific quality/cost information is generated in Collaborative PBM Cloud™
  • When clinical/pharmacy staff of a plan sponsor need to be involved in real-time collaborative decision making for better health outcomes

Compliance Management Services

RxAdvance’s guiding principles include interpreting the CMS/state/plan sponsor-specific compliance guidelines, building consensus between plan sponsors and RxAdvance, and configuring the Collaborative PBM Cloud™ to achieve the highest possible degree of compliance automation with minimal personnel involvement.


Overarching line of business guidelines: RxAdvance’s Collaborative PBM Cloud™ comes with built-in library of federal and state compliance guidelines that were interpreted and configured into the system so that compliance is accomplished both at transactional and operational levels.

Plan sponsor benefit design guidelines: As part of onboarding a plan sponsor, RxAdvance SME’s evaluate, interpret, and configure plan sponsor benefit design guidelines. Leveraging Collaborative PBM Cloud™, RxAdvance brings transparency to plan sponsors by seamlessly sharing the interpreted configuration. Upon approval by the plan sponsor, RxAdvance promotes the configuration to production.

Ongoing regulatory compliance changes: RxAdvance SMEs provide up-to-date responses to federal guidance and new and pending legislation. RxAdvance is part of a compliance coalition team that participates in weekly user calls and industry conferences and monitors the direction of federal programs.

PBM Service Level Agreement (SLA) Compliance: Collaborative PBM Cloud™ enables RxAdvance to configure all elements of plan, sponsor-specific ALAs, providing service delivery staff with tools and workflow triggers to meet SLA requirements. Through AdvanceESM, RxAdvance provides service managers and plan sponsor supervisors full and complete access to real-time service level activity.

Leveraging AI driven algorithms, Collaborative PBM Cloud™ continuously monitors preset service delivery thresholds which are configured during onboarding of a plan sponsor. This monitoring process proactively auto-triggers changes to service delivery resources including activation of third party overflow vendors to fulfill all agreed upon service levels. Proposed benefit design changes, (e.g. formulary/prior authorization modifications) can be modeled to promote effective service delivery management.

Audit Support: RxAdvance believes in giving full transparency to the plan sponsor regarding all PBM-related activity, eliminating the need for onsite plan sponsor audits. When it comes to regulatory agency audits, RxAdvance provides full access to the “auditor role” using role-based security. Through this role, the auditor is able to inspect the system-configuration rules, simulate a transaction, and validate the outcome. In addition, the system provides complete access to all member-level transactional information.

The table below illustrates a representative set of compliance requirements that are automated through Collaborative PBM Cloud™

Compliance RequirementRxAdvance Automation
MTMSystem monitors patient prescriptions, triggers alerts, pre-populates CMR, generates PML and MAP, and queues up the P4P payment to support CMS mandated MTM requirements
Concurrent DURProcesses and analyzes all patient data (including drug, medical, dental, and lab) to send customized notifications to pharmacists and prescribers.
Coverage determinationsMonitors all determination requests against CMS guidelines from receipt to disposition and autogenerates all required documentation ensuring 100% compliance
Appeals and grievancesMonitor all five levels of appeals with automated timeline reporting and escalation protocols to ensure compliance with all guidelines
Formulary administration and changesBuilt-in CMS and HIX formulary requirements identify invalid RxCUIs, negative formulary changes, and tier formation and structural questions to eliminate compliance issues with benefit design changes
Rejected claims monitoringAutomated triggers to monitor all rejected claims for re-validation to eliminate audit issues and improve patient experience
Benefit coding and testingSimple setup, customization, and testing of more than 300 benefit designs
Part D reporting and data validationPre-validated Part D reporting structure and guidelines to automatically generate accurate and timely reports
Claims processing systemsAutomated override procedures for transition policies, emergency fills, LTC requirements, and custom messaging at POS to minimize invalid rejections
DEA validationComprehensive DEA database for real-time monitoring of incoming prescription types, DEA license types, and providers for accurate adjudication
Transition policyBuilt-in transition policy requirements to accurately track and identify existing and new patients, medications, and place of service
Part D reporting and data validationComprehensive data structure and analytics to identify patient location, disease state, medication, and enrollment history to auto-adjudicate potential Part B versus Part D reimbursement scenarios
TrOOP balanceAutomated capabilities to track and maintain TrOOP balances for new and existing patients

Global Pharmacy Risk Management

RxAdvance’s unique value proposition to plan sponsors includes the sharing of global pharmacy risk. In this partnership model, RxAdvance stands shoulder-to-shoulder with plan sponsors to share pharmacy and drug-imimpacted medical risk sharing.

RxAdvance’s global pharmacy risk management has two components:
1) Pharmacy risk sharing; and 2) Drug‐impacted medical risk sharing.

RxAdvance’s Global Pharmacy Risk Management 5-phase program includes:


  1. Analysis – RxAdvance seeks to identify all the relevant opportunities and risks for plan sponsors. RxAdvance aggregates all available data from medical claims, pharmacy claims, and clinical data to offer a comprehensive analysis of prior drug utilization. This analysis is accomplished by running historical data through Collaborative PBM Cloud™ platform, which applies artificial intelligence (AI) algorithms to list opportunities for plan sponsors. Possible opportunities include but are not limited to: 1) untapped generics usage; 2) medication therapy management (MTM) and coverage gap avoidance (CGP³); 3) medication adherence management (MAM); 4) effective specialty management; 5) increase in pharmacy related STAR ratings; 6) administrative fee savings; 7) unit drug cost savings; 8) increase in rebate income; 9) fraud, waste, and abuse-related opportunities and 10) avoidable drug-impacted medical costs.
  2. Engagement – RxAdvance engages the plan sponsor’s clinical/pharmacy staff to discuss opportunities and risks and collaboratively decide on program options. Based on the programs identified, RxAdvance engages with pharmacists at the point of sale while the plan sponsor engages with prescribers at the point of care and with members proactively.
  3. Implementation – RxAdvance collaboratively implements programs identified in the engagement process step. As part of the implementation stage, key performance metrics, success criteria, and program monitoring timelines are defined. All computations are clearly documented before the programs are initiated to ensure consistency of measurements.
  4. Monitoring – Each program is continually monitored for effectiveness and to identify any opportunity for appropriate recalibrations in order to achieve best possible results.
  5. Cost reduction – RxAdvance works withplan sponsors to compute cost reduction opportunities and the mitigation of clinical risks. Based on the clinical results accomplished and cost savings achieved, risk or reward is shared between the plan sponsor and RxAdvance in accordance with predefined contract terms.


Pharmacy Risk Sharing

The first step is to establish a projection of national pharmacy costs in theupcoming period using defined industry financial benchmarks. RxAdvance analyzes available information for trends and establishes a projected cost increase below this benchmark.

For example, if the national benchmark projects an increase of 5%–7% annually, then RxAdvance sets its RISK CAP at 4%. Current year pharmacy costs = $200M.Contract terms will thus be:

  • Contract year pharmacy costs should have been = $212M (6% increase as per the agreed national benchmark).
  • Plan sponsor reimburses RxAdvance = $208M (4% as per agreed RISK CAP).
  • Plan sponsor projected pharmacy cost savings = ($212M – $208M) = $4M

Scenario – A

  • For the contract year, the actual pharmacy costs = $200M.
  • RxAdvance saves = $208M – $200M = $8M.
  • RxAdvance reimburses 25% of the savings to plan sponsor = 25% * $8M = $2M

Scenario – B

  • For the contract year, the actual pharmacy costs = $214M
  • RxAdvance takes risk of $214M – $208M = $6M.
  • Plan sponsor reimburses 25% of the risk to RxAdvance = 25% * $6M = $1.5M

Drug-impacted Medical Risk Sharing

  • RxAdvance will work collaboratively with plan sponsors to establish the basis-for-computing drug-impacted medical costs out of total medical costs. This analysis leverages prior year(s) medical claims data to compute drug-impacted medical costs. Based upon these findings, RxAdvance and the plan sponsor mutually decide on the targeted cost reduction figure for the contract year. During the contract year, RxAdvance closely monitors actuals versus projections and works with the plan sponsor to ensure overall quality of care is optimized.
    • For example, current year total medical costs = $800M and current year drug-impacted medical costs = $200M.
  • Upside Scenario
    • Contract year actual drug-impacted medical costs = $150M
    • RxAdvance gets reimbursed from plan sponsor 25% of contract year savings = $200M-$150M =(25% * $50M) = $12.5M

In this way, RxAdvance offers a revolutionary global pharmacy risk sharing partnership that is unique in the PBM market place. To see what your actual savings could be, please contact RxAdvance for a demonstration at