MutualRx Services
Our Services include:
Claims
Adjudication

Our claims system processes over 1 billion prescriptions annually.  It is time-tested and cost-effective. We embed reference-based pricing that is applied to over 70 therapeutic classes and dramatically reduces plan and member costs.

Payment &
Invoicing

Our proprietary payment system enables us to pay network pharmacies almost immediately and produces additional quick-pay discounts at retail, which are passed-through to clients. Invoicing to clients is at exactly the same reimbursements made to the pharmacy.

Network Contracting

We offer a broad 65,000 store national network and customized “right-sized” narrow networks to meet the needs of your members. Additional discounts belong to the client plan and their members.

Rebate
Contracting

Our rebate contracts have been aggressively negotiated and offer extremely competitive rebates. Our goal is to develop a lowest net cost drug mix with demonstrated reduced costs to the plan and their members.

Mail Service

Mail service is available through several mail order facilities that can be contracted at the selection of our client partners. Our incentives are completely aligned with our clients, and we are only interested in having prescriptions filled at the lowest cost, high quality facility.

Clinical Programs

Utilization review, step-therapy, prior-authorizations, quantity and dosing limits, medication therapy management, opioid abuse, pain management, disease management and other clinical support programs.

Specialty Drugs

A diagnostic analysis is performed to review both pharmacy and medical claims related to Specialty. Customized intervention programs are created that include contracted fulfillment pharmacies, site of care plan design, coordinated prior authorizations, medical plan formulary, rebates and other specialty drug management techniques. As with Mail, we do not require Specialty Drugs be limited to a PBM-owned pharmacy. As an equity client, your plan and members will receive whatever options are in your best interest.

Formulary Management

A national preferred formulary or customized formularies are available to all MutualRx clients. Open or closed, incentive or access, can all be provided. It’s your plan, your money, your formulary.

Reporting

A complete array of management reports  are provided on a quarterly basis that describes member utilization and plan performance. Customized dashboards can be created to meet each client’s personalized preference in seeing plan details. These reports are also presented annually as an overall trend report.

Call Center

Our call center is 100% U.S- based and provides knowledgeable and courteous support to plan members on a 24/7 basis. Additionally, our pharmacy desk is connected to the call center, so member concerns regarding questions that occur at the retail pharmacy level can be resolved quickly and efficiently with minimal member disruption.

Member Services

Our online shopping tool and mobile app assist members in reviewing alternative medications and finding the lowest-cost channel and location for getting their prescription filled. Access to a pharmacist is available on a 24/7 basis. Member portal brings disease management and other clinical communications to members on demand.

Plan Surveillance

We provide plan utilization surveillance so plan administrators can have access to monthly plan performance if they desire. This monitoring will identify any problems occurring in the plan, including fraud, waste and abuse, unusual prescribing patterns or over-utilization at the individual pharmacy level, and alerts us to take corrective measures.

How Traditional PBMs
Make Money

Pharmacy contracts between PBMs and pharmacies are some of the most highly guarded secrets in the industry! PBMs claim that these “secret” arrangements are necessary in order to negotiate the best deals on behalf of their clients. In reality, their revenue streams include:

  • Administration Fees
  • Spread Pricing
  • Repackaging
  • Rebates
  • Data Fees
  • Grants
  • Float
Maximum Allowable Cost (“MAC”)
  • Established by PBM for pricing generics
  • PBM sets the price, # of drugs, and can change the list at their discretion
  • The PBM can have multiple MAC lists for different clients and different retail pharmacies
  • The MAC list used for reimbursing pharmacies may not be the same MAC list used to bill the client