SmithRx supports medication adherence and positive health outcomes by offering resources and tools that help patients manage their prescriptions. For example, SmithRx members have access to the SmithRx Member Portal, which displays cost-saving options, such as generic alternatives, and coverage and pricing details to help patients make informed choices.

SmithRx prioritizes fair and transparent interactions with a broad network of pharmacies, including independent and community-based pharmacies, to support a competitive and accessible marketplace. We value our partnerships with independent pharmacies and work together to provide affordable care for our members.

A Pharmacy and Therapeutics (P&T) Committee is made up of practicing physicians, pharmacists, and other experts in the treatment of disease and preservation of health who use the clinical effectiveness, safety, and value of a drug to determine a drug’s formulary status. The primary purpose of the formulary is to encourage the use of the most affordable, safe, and effective drugs. The P&T committee may utilizes resources like medical literature, clinical trials, FDA-approved information, and clinical guidelines. This committee regularly reviews new-to-market drugs and existing drug classes to determine which medications to include on a PBM’s formulary, focusing on the safest, most effective, and most affordable options. Key factors assessed include safety, efficacy, dosing, administration, and its place in therapy compared to alternatives.

PBMs negotiate with drug manufacturers on drug pricing, rebates, formulary management, and other topics. At SmithRx, we work with manufacturers to bring affordable, quality options to our members. We ensure savings reach our clients by passing along 100% of all rebates without retaining any portion. This commitment to transparency helps make healthcare more affordable and accessible for everyone.

PBMs manage relationships with mail-order pharmacies, allowing patients to conviently receive prescriptions directly to their home. They negotiate prices, process claims, and facilitate 90-day supplies when allowed based on plan design, which can reduce costs on long-term medications. Some PBMs own mail-order pharmacies, giving them direct control over pricing and distribution, though this may not always align with patient or plan goals. SmithRx, however, does not own any mail-order pharmacies; instead, we partner with a wide range of pharmacies, offering members flexible, cost-effective options for specialty and non-specialty medications.

To find out if your insurance covers a specific medication, you can check your plan’s formulary or prescription drug list, which will show covered medications and any requirements like prior authorization (PA) or step therapy (ST). A PA means your doctor must get approval before the insurance will cover the drug, while ST requires trying a lower-cost medication first. SmithRx members can log into the SmithRx Member Portal to compare prices, check coverage, and view any requirements in real-time for medications at different pharmacies in their area.

Both brand and generic drugs must meet FDA standards for safety, effectiveness, and quality. Generics contain the same active ingredients, are similar in dosage and formulation (tablet, capsule, liquid, injectable, etc), and can work just as well as brand-name drugs. One main difference is cost—generics are generally less expensive. Additionally, multiple manufacturers can produce a generic drug, increasing competition and driving prices down, ultimately leading to lower costs for patients with providing the same clinical benefit.

SmithRx members have access to a range of options designed to balance affordability and convenience when filling prescriptions. Independent pharmacies often provide low-cost medications with the added benefit of personalized service. Mail-order services, such as Amazon Pharmacy and Mark Cuban's Cost Plus Drug Company, offer affordable medications delivered directly to your doorstep for added convenience. Members can easily use the SmithRx Member Portal to find the local or mail-order pharmacy offering the lowest cost for their prescriptions.

Amazon Pharmacy makes it easy to get prescriptions through the mail—another convenient mail-order option. Members can link your health plan for clear pricing, order up to a 90-day supply for some long-term medications, and have them delivered right to your door. Prime members enjoy free two-day shipping with secure, discreet delivery. SmithRx is excited to partner with Amazon Pharmacy, offering SmithRx members another hassle-free way to manage prescriptions, eliminating the need for in-person pharmacy visits, while providing a simple, transparent service for getting the medications you need.

A drug rebate is a partial refund given by drug manufacturers to PBMs or health plans based on the volume of drugs sold. Depending on the PBM, rebate savings may be shared with plan sponsors, but transparency around rebate handling varies. Legacy or traditional PBMs may retain a portion or all of the rebate as a revenue source, while SmithRx passes 100% of rebates directly to clients, helping to lower drug costs for both employers and members.

A drug rebate is a payment given by manufacturers to PBMs or health plans, often negotiated to secure a drug's inclusion on a PBM’s formulary. Rebates, especially for high-cost drugs, can be substantial. Legacy PBMs often withhold all or a portion rebates, resulting in higher net costs to plans and patients. Modern PBMs like SmithRx pass through rebates so that employers and patients benefit.

Biosimilars are drugs that are highly similar to an already approved biologic treatment, called a reference product. Much like how generic drugs are similar to brand-name medications. Unlike generics, which are identical to their brand counterparts, biosimilars are not exact copies because they are derived from living organisms. Despite this, biosimilars have no clinically meaningful differences in safety, purity, or potency compared to the reference product. They are often priced lower, providing a cost-effective alternative, and PBMs may include them on formularies to help reduce drug costs while maintaining effective therapy and care.

A Maximum Allowable Cost (MAC) list is a price guide that a PBM can use to determine reimbursement to a pharmacy for generic drugs. When multiple generics are available, they often come at varying prices for pharmacies. The MAC list can help minimize excessive pricing so that health plans do not overpay for commonly prescribed generics. Pharmacies are incentivized to purchase these medications at competitive prices, benefiting both health plans and patients by keeping drug costs lowers while maintaining access to medications.

A benefits broker can help employers navigate complex health insurance and pharmacy benefit plan design options to meet the organization's specific needs. A good broker provides critical insights on cost-effective PBM options, helps manage plan implementation, and supports employers in designing plans that are in the best interest of their employees. Their role can be especially valuable in ensuring transparency in PBM pricing models and that the plan design aligns with the employer's goals.

Spread pricing and pass-through pricing are fundamentally different pricing models distinguishing legacy PBMs from modern PBMs. In spread pricing, the PBM charges its health plan client more than it pays the pharmacy, keeping the difference as profit. This means saving are not passed onto the client or its members, often contributing to the high price of prescription drugs. Pass-through pricing, on the other hand, is a more transparent model where the PBM charges the health plan the amount paid to the pharmacy. Legacy PBMs often rely on spread pricing for revenue, while modern PBMs like SmithRx focus on transparency and pass-through the cost without any hidden mark-ups.

Non-formulary drugs are medications that are not included in a health plan's list of covered drugs, also known as the formulary. This means that the plan may not cover the cost of these medications. The decision to exclude certain drugs from a formulary may be based on cost, availability of more cost-effective alternatives such as generics or biosimilars, or the clinical efficacy of the medication. Depending on the plan benefits, patients may still be able to access non-formulary drugs by paying the full price, or in some cases, through a special request process where the provider can explain the reason for the non-formulary medication.

A formulary is essentially a prescirption drug list that includes all the prescription medications covered under a health insurance plan, including generics, biosimilars, and brand-name drugs. It’s typically categorized by cost tiers (such as preferred and non-preferred drugs) and developed based on clinical efficacy, safety, and cost. Formularies guide providers and patients in selecting the most appropriate and cost-effective treatments. This makes it clear to employees which medications are available and affordable under their pharmacy plan.

A legacy or traditional PBM refers to PBMs that have been in the industry for many years, typically using opaque pricing model, are affiliated with insurance companies and/or pharmacies, use complicated rebate and contract structures, and impose hidden fees. The three largest legacy PBMs include OptumRx, Express Scipts, and CVS Caremark. In contrast, modern PBMs like SmithRx prioritize transparency, a focus on net costs, and aligning their incentives with the best interests of clients and patients.

PBMs can generate revenue from several sources. Legacy PBMs often use methods like rebate capture (i.e., keeping a portion or all of manufacturer rebates on high price drugs), spread pricing, MAC list manipulation, and owning mail-order or specialty pharmacies, which can create hidden costs leading to increased pharmacy spend. In contrast, SmithRx uses a straightforward administrative fee structures, giving clients clear visibility into where their money goes and helping them achieve greater savings.

Yes, legacy PBMs are owned or affiliated with large healthcare organizations. For example, Express Scripts is owned by Cigna, and Optum Rx is owned by UnitedHealth Group. SmithRx, however, is independent and prioritize transparency and cost savings, while insurer-owned PBMs may have other incentives that could potentially conflict with the goals of their clients and impact patient drug pricing and access.

PBMs negotiate with drug manufacturers and pharmacies to control prescription drug costs and determine how medications are covered and reimbursed. They secure discounts from pharmacies and rebates from manufacturers, aiming to reduce overall expenses for health plans and patients. PBMs also process prescription claims, ensuring members pay the correct amount based on deductibles and coverage criteria. PBMs also manage formularies, which can help guide patients and providers toward cost-effective treatments such as generics or biosimilars while supporting access to necessary medications. Additionally, PBMs implement strategies such as prior authorization and step therapy, along with other cost-containment measures, to optimize both costs and care quality.

A Pharmacy Benefit Manager (PBM) manages prescription drug benefits on behalf of health plans, employers, unions, and government programs. PBMs serve as intermediaries between drug manufacturers, pharmacies, and health insurance plans to manage prescription benefits and process drug claims.

Tirzepatide is the first GLP-1 with an additional mechanism of glucose-dependent insulinotropic polypeptide (GIP) receptor agonist and is used for the treatment of type 2 diabetes and chronic weight management. The dual GLP-1/GIP mechanism of action is thought to be an enhanced GLP-1, with greater effects on blood sugar control and weight management.

Semaglutide is used to treat type 2 diabetes and chronic weight management. It is a glucagon-like peptide-1 (GLP-1) receptor agonist, which means it mimics the effects of the natural hormone GLP-1.  Semagltuide has been shown to be effective in lowering blood sugar levels and aiding in weight loss. 

Compounded GLP-1s are typically supplied in multi-dose vials and measured using a syringe. Brand products are supplied as prefilled pens devices. 

In addition to controlling blood sugar and promoting weight loss, some GLP-1 medications have kidney and heart benefits, such as reducing the risk of heart attack and stroke. There is ongoing research into new indications and beneficial uses of GLP-1s. 

The most common side effects of compounded GLP-1s are similar to the commercial GLP-1s, and include nausea, abdominal pain, constipation, and vomiting. These side effects are typically mild and usually go away over time as the body adjusts to the medication. It is important that patients consult with their provider regarding the use of compounded GLP-1s. 

Compounded medications can be used, in situations when a specific medication must be made for one person (e.g., due to an allergy to an inactive ingredient contained in the brand or generic version of a drug), or when drugs are on the FDA’s Drug Shortages list to ensure you have access and  can continue taking your medication for treatment. 

Compounding pharmacies that meet the requirements of the Federal Food, Drug, and Cosmetic (FD&C) Act and use the base formulation–not the salt form– use the same active ingredients as semaglutide commercial products. 

‍

GLP-1s may be prescribed by providers for diabetes and obesity. With the rising demand, there are also direct-to-consumer options for weight loss. 

‍

Alarmingly, 38% of respondents of a 9amHealth study³ have tried knock-off GLP-1s/semaglutide or black market weight loss products, greatly increasing the risk of complications or adverse reactions as these drugs could contain contain too little, too much or no active ingredient at all, or contain the wrong of other harmful ingredients.  The FDA recommends that individuals should only get compounded semaglutide from state-licensed pharmacies or outsourcing facilities registered with FDA.⁴

According to a study by PSG², the top cost containment strategies are prior authorization, Body Mass Index (BMI) requirement, quantity limits, comorbid condition requirement, step therapy, and lifestyle modification program participation requirement.

GLP-1 therapies, first approved in 2005, have been part of the pharmacy landscape for nearly two decades. Recently, their demand has surged due to their effectiveness and benefits, such as treating obesity and reducing cardiovascular risks. GLP-1s are also being studied for treating various chronic diseases like heart failure, obstructive sleep apnea, and liver disease. Their future growth is expected to continue, driven by their efficacy and safety, the rising prevalence of diabetes and obesity, and new FDA- approved indications, likely making them a significant driver of employer plan sponsors’ pharmacy benefits spending.

As of July 2024, due to increased demand, there is a FDA nationwide shortage of GLP-1 medications (specifically, Semaglutide injections and Tirzepatide injections). To ensure continued access to medications on the FDA’s Drug Shortages list, compounded versions using the same active ingredients may be made during such shortages under certain conditions and state and/or federal requirements.

Glucagon-like peptides-1 receptor agonists (GLP-1s) and Glucose-dependent Insulinotropic Polypeptide receptor agonists (GIP) are medications that mimic hormones naturally produced by the body. When referring to ‘GLP-1s', this includes GLP-1s and dual GLP-1s/GIPs. The Food and Drug Administration (FDA) has approved several GLP-1s to treat type 2 diabetes, obesity, and reduce the risk of cardiovascular disease.

Pharmaceutical Strategies Group (PSG) reported¹ that nearly 80% of health plans and employers respondents were moderately or very concerned about the affordability of GLP-1s. According to the same PSG report, 91% of health plans and employers currently cover GLP-1s for type 2 diabetes, while 33% cover them for obesity.

If you are on vacation and are in need of medication (because medicine was forgotten or you ran out), there are a number of options depending on where you are vacationing and what medicine(s) you need. Often, the best solution is to have a pharmacy near you contact the pharmacy where you normally fill prescriptions to transfer the prescription to refill there. If it is too soon to refill, in order to avoid running out of medicine, you can call our customer service number at 844-454-5201, and we can work with you to find a solution.

Filling and delivery of mail order prescriptions, both new and refilled prescriptions, are managed by the mail order pharmacy contracted with your insurance plan. For the most up-to-date status of a mail-order prescription or delivery, you can call the mail order pharmacy directly. If you have any trouble calling the mail order pharmacy, you can also call our customer service number and a member of our team can coordinate with the mail order pharmacy to help you with a status update.

Auto-fill (or auto-refill) is a convenient and time-saving option for most of your mail order prescriptions. Opting-in for auto-refill may allow you to maintain consistency in taking your medications. As such, it is a great option for chronic medicines that you take regularly and are important to take consistently. For medicines not on auto-refill, you would need to order each refill, requiring you to plan and call early to allow enough time before you run out of medicine. For prescriptions on auto-refill, instead of contacting the mail order pharmacy each time you need a refill, the medicine is automatically refilled and delivered to you according to your prescription schedule. To place a prescription on auto-refill, you will need to call your plan’s mail-order pharmacy to opt-in for each prescription that you would like on auto-refill. If at any time your doctor stops a medicine that was on auto-refill, please call the mail order pharmacy to let them know that you are no longer taking this medicine to avoid being charged and sent medicine you no longer need.

Quantity Limits specify a maximum dosage or quantity that will be covered (for example, a maximum number of tablets per day). These quantity limits often reflect safe and effective doses for a given medication. Any dosing (reflected in quantity per day) up to the quantity limit will be covered, but dosing quantities above the quantity limit will be initially rejected. In order for any prescription exceeding a formulary quantity limit to be covered, the prescribing doctor will need to apply for a prior authorization, providing medical justification for the higher dosing to be reviewed by our clinical team.

Sometimes you can’t use your pharmacy benefits when you’re at the pharmacy. If that happens, you can download the reimbursement form from your member portal account and submit it to us and we’ll help you get your money back. If you’re not registered, call our customer support team at 844-454-5201 and we can email the form to you and answer any questions about the process. Reimbursement for these prescriptions will be based on your benefit plan design.

Register for a secure SmithRx account at: https://mysmithrx.com/. From the member portal, you can look up medications and see your out of pocket costs. Members can find in-network pharmacies from our national network of over 70,000 participating locations. Download mail order and prior authorization forms, review claims and find employer specific customer service contact information for any of your pharmacy service needs.

Generic, Preferred Brand, and Non-Preferred Brand drugs refer to classifications of drugs that correspond to Tiers (Tier 1 through Tier 3) in your prescription benefits plan. Copay, in addition to other factors such as day supply of the prescription, is determined by the drug’s tier. Your prescription drug plan may designate certain brands as preferred (typically Tier 2) and some as non-preferred (Tier 3). Brand name drugs tend to be more expensive. Generic versions of those brand name drugs have the same active ingredients but tend to be less expensive. For example, Tylenol is a brand drug and acetaminophen is its generic equivalent.

Use our mobile site to securely and easily manage new prescriptions. All of your member information is included in a handy electronic ID card.

Log on to your member portal for quick access to the information and instructions to fill your prescription. To reorder your ID card, call SmithRx at 844-454-5201 or submit a card request form.

Step Therapy is a condition in which certain drugs require other medications to be tried before they can be covered by insurance. Step Therapy may have one or more levels of criteria (steps) that must first be fulfilled. If your doctor prescribes, or wants to prescribe, a medication that requires step therapy, he/she can call 844-512-3030 to work with our clinical team to coordinate therapy and determine what is needed.