CareReview / Who We Serve / PBMs
Independent Review PBMs Can Stand Behind
Specialty-matched clinical experts who protect PBM neutrality and build plan sponsor confidence in every determination.
Independent Review PBMs Can Stand Behind
Specialty-matched clinical experts who protect PBM neutrality and build plan sponsor confidence in every determination.
We help PBMs manage pharmacy benefit reviews — prior authorization through appeals, external review, and payment integrity — with independent, specialty-matched clinical experts who strengthen compliance, protect PBM neutrality, and build plan sponsor confidence in every determination.
The Pressure PBM Teams Are Under
- Pharmacy PA volumes are surging with specialty drug growth — GLP-1s, biologics, gene therapies — straining internal clinical capacity and step-therapy exception processing.
- Formulary exception and appeal backlogs are growing, and independent clinical expertise for specialty therapeutic areas is hard to sustain at scale.
- Seasonal volume spikes — January formulary resets, open enrollment plan changes, mid-year specialty renewals — hit all at once, and internal teams sized for average volume can't absorb the surge without backlogs building.
- Plan sponsors and regulators are asking harder questions about conflict of interest when a PBM reviews its own coverage denials.
- Plan sponsors increasingly audit PBMs to prove payment accuracy on complex, high-risk specialty and compound drug claims.
Independence Is the Credibility Card
Every CareReview determination follows a specialty-matched pharmacy review — pharmacy technicians handle intake and coding validation, licensed pharmacists issue the clinical determination, and physician specialists step in on complex cases — all outside the PBM's own process, with written, evidence-based rationale that holds up to plan sponsor scrutiny and regulatory review.
How CareReview Helps PBMs
Coverage Determinations
Fast, evidence-based pharmacy prior authorization determinations that reduce formulary exception backlogs, ensure appropriate member medication access, and help plan sponsors control cost. Backed by a pharmacy technician, pharmacist, and physician review team with deep specialty expertise across all major drug categories — technicians handle intake and coding validation, pharmacists issue clinical determinations, and physician specialists step in on complex cases.
Pharmacy Appeals
Independent, specialty-matched clinical experts resolve pharmacy benefit appeals — strengthening compliance, protecting PBM neutrality, and building plan sponsor confidence in every determination, with rapid turnaround to meet state-mandated appeal deadlines.
External Review
State and federal external review obligations fulfilled through our URAC-accredited IRO, available nationwide — timely, defensible pharmacy benefit determinations from one partner covering both medical and pharmacy reviews.
Payment Integrity
Pharmacist- and physician-led claim validation protects plan sponsor spend, applying the same clinical precision used in prior authorization and appeals to catching inappropriate payments and billing errors.
Why CareReview for PBMs
- Pharmacist and physician team with deep specialty expertise across all major drug categories, using evidence-based criteria aligned to current clinical guidelines and formulary standards.
- Scalable reviewer network absorbs seasonal volume spikes — January formulary resets, open enrollment, specialty renewals — so turnaround times hold steady at peak season instead of sliding into backlog.
- URAC-accredited IRO, HITRUST certified, and available nationwide — NCQA accreditation expansion underway.
- Stradix® platform integrates with PBM workflows and case management systems.