NANO PBM

Frequently asked questions

What is pharmacy benefit management?

Pharmacy benefit management is the administration of a prescription drug benefit on behalf of a payer, health plan, employer or government. It covers deciding which medicines are covered and on what terms, authorising them where authorisation is required, processing and adjudicating the pharmacy claims, managing the pharmacy network, and controlling what the benefit costs without reducing access to the medicines patients need.

What is a formulary?

A formulary is the list of medicines a plan covers, usually organised into tiers that determine how much the plan pays and how much the member pays. It is the central control in any pharmacy benefit: it decides what is available by default, what needs extra approval, and where a cheaper clinically equivalent option should be offered first.

What is prior authorization?

Prior authorization is a check before a medicine is dispensed, used where a drug is expensive, clinically risky, or only appropriate for a narrow group of patients. The prescriber submits clinical justification and the plan approves or declines against its rules. It is the single biggest source of friction in a pharmacy benefit, which is why automating the approval path is where most of the value is.

How automated is the approval process?

NANO PBM targets full automation of pharmacy approvals and claims processing, so routine decisions resolve against the rules without a human touching them and clinical review is spent on the cases that genuinely need judgement.

What are rebates, and why do they complicate this?

A rebate is an amount returned by a manufacturer to a payer or plan after a medicine has been dispensed, usually tied to volume or formulary placement. Because it arrives after the fact, the price a plan appears to pay and the price it ends up paying are different numbers — which is why analytics over the whole benefit, rather than over individual claims, is the only way to see what a drug actually costs you.

Who are the different users of the platform?

Three groups, each with their own channel: payers administer the benefit and its rules through the payer portal; providers and pharmacies submit and check authorisations and claims through the provider portal; and members see their own coverage and prescriptions through the mobile app. Putting all three on one platform is what removes the phone calls between them.

Does it work across different countries and regulators?

It is built to. The platform uses international medical classification aligned to WHO codes and is designed to meet the requirements of each regulator across more than 36 countries, which matters for any payer or group operating in more than one market.

How does it relate to drug data?

Closely, and it is the part most easily underestimated. Coverage rules, interaction checking and equivalence decisions all depend on a maintained drug knowledge base underneath them. NANO PBM draws on NANO IDDK, the international drug data knowledge base, rather than on a list maintained per deployment.

Where does fraud, waste and abuse detection fit?

Pharmacy is one of the places it concentrates, because volumes are high and individual amounts are small. Claim process management covers the journey from first notification through fraud detection and adjudication to settlement, and NANO BRAIN contributes the denial and deduction patterns it has learned across processed claims.

What does the analytics actually tell us?

Where the benefit is spending and why: which drugs and categories drive cost, where utilisation is out of line with the clinical picture, how approval and rejection rates vary across prescribers and pharmacies, and where a formulary change would have the largest effect. The point is lower prescription drug costs without cutting access to the medicines patients need.