What Makes CapitalRx Different from Traditional PBMs?

Traditional pharmacy benefit managers (PBMs) often operate with hidden margins and misaligned incentives. They may:

• Keep a portion of manufacturer rebates instead of passing them back.
• Use “spread pricing,” where they charge the employer more than what the pharmacy is paid.
• Design formularies that favor higher-cost drugs because they generate bigger rebates.
• Leave employers in the dark on the true net cost of medications.

CapitalRx is different. Self Fund Health chose them because their model aligns directly with our strategy of transparency and real-time savings.

• NADAC-Based Pricing: CapitalRx ties drug costs to NADAC (National Average Drug Acquisition Cost)—a publicly available benchmark published by CMS. This ensures employers pay a fair, transparent cost based on what pharmacies actually pay to acquire medications. No spreads, no hidden markups.
• Single-Ledger Model: Employers see the same transaction that pharmacies are paid, creating a clear, auditable trail.
• Transparent Rebates: All manufacturer rebates flow back in full to Self Fund Health, which then delivers them to employers through Melio six months after the end of each quarter.
• Aligned Formularies: Formulary decisions are based on clinical value and lowest net cost, not on maximizing rebate revenue.
• Technology Integration: CapitalRx integrates directly with our systems to enable real-time prescription shopping, cost estimates, and steerage for members.
• Supports Carveout Programs: Through specialty sourcing options (like CanaRx), we can provide zero-dollar options for high-cost medications that would otherwise burden employers.

Key takeaway: Traditional PBMs profit from opacity. CapitalRx anchors pricing to NADAC, eliminates spread, returns all rebates, and integrates with Self Fund Health’s technology—keeping incentives aligned with employers and members.