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A payer-funded benefit card
The payer funds a benefits vendor and bank. The member taps the card at the pharmacy. The pharmacy asks the vendor to approve and the vendor pays the pharmacy. A rules check sits under the vendor.
Payer
the health plan
Benefits vendor
and the issuing bank
Pharmacy
terminal
Member
taps the card
Rules check
approve, hold or decline
funds the card
pays
approve?
tap
asks
The pharmacy benefit route
The member shows the card at the pharmacy. The pharmacy sends a claim with BIN, PCN and Group to a pharmacy benefit manager. The manager answers with approval and the copay. The payer pays the manager. How the pharmacy is paid is not confirmed.
Pharmacy
sends the claim
Pharmacy benefit
manager (PBM)
Payer
the health plan
Member
shows the card
Card carries BIN, PCN, Group
no payment card involved
claim
approved, copay
pays
How the pharmacy is paid is not confirmed
The member's own account
Money goes into a member's HSA, FSA or HRA account at an administrator. The member taps a debit card at the pharmacy. The pharmacy system checks which items are eligible and the administrator pays only for those.
Member's card
debit card
HSA, FSA or HRA
held by an administrator
Pharmacy
checks eligible items
Member or employer
puts money in
draws on
eligible only?
pays