Question 1

Does ApalyRx replace our PBM?

Accepted Answer

No. It runs in front of the benefit and routes through your PBM whenever your PBM is the lowest cost. Formulary, tiers, prior authorization, and benefit design stay exactly where they are.

Question 2

What does it cost, and what if there are no savings?

Accepted Answer

There is no setup cost and no fee unless a script routes below what your plan would have paid. If there is no savings, there is no charge. So the question is less what it costs and more what it returns, because you are only ever sharing money you were not going to keep.

Question 3

Is this only for high-cost drugs?

Accepted Answer

No. We source both generic and brand medications below what the plan and member pay combined, which is why savings appear on the large majority of scripts. High-cost drugs carry most of the dollars, but they are not the whole program.

Question 4

What exactly happens on a script, end to end?

Accepted Answer

The prescription routes to ApalyRx, eligibility and plan type are confirmed with your TPA in real time, and the member is texted with their options. If the member is on an HDHP, their current deductible balance is retrieved at that moment and cost share is calculated and collected accordingly. The claim is submitted to your TPA with drug, NDC, dose, and plan amount, and any member cost share is reported so it posts to the accumulator and out-of-pocket maximum.

Question 5

How does this work for members on an HDHP?

Accepted Answer

Cost share is calculated against their real-time deductible balance and collected at the point of fill, which is what keeps HSA and HDHP treatment intact. Once the member has satisfied the statutory deductible, the zero out-of-pocket option becomes available. Members on a PPO reach zero cost share immediately.

Question 6

What if our PBM will not share true post-rebate pricing?

Accepted Answer

Then we cannot evaluate that channel, and we route only across the channels we can price. It is worth asking what it means for your fiduciary process if a material share of plan spend cannot be verified at all.

Question 7

How will our PBM respond?

Accepted Answer

Structurally, members choose where their prescriptions are sent, your PBM continues administering the benefit, and volume routes back to them whenever they are lowest. As with any benefit change, your plan counsel should review the arrangement against your existing contracts.

Question 8

What is the hybrid carve-out model?

Accepted Answer

Some employers carve specific high-cost drugs to ApalyRx exclusively, so those drugs reject at retail under the PBM benefit and fill through ApalyRx instead. The carve-out is limited to drugs we can access at a lowest contracted net cost, scripts fill per the prescriber's order.

Question 9

How are biosimilar conversions handled?

Accepted Answer

When a plan has committed to a specific biosimilar, the dispensing pharmacist is notified and compensated to conduct the clinical conversation with the prescriber and obtain a new order. The conversion happens through a clinical discussion, not an administrative substitution.

Question 10

Is this on benefit, and does cost share count toward the deductible and MOOP?

Accepted Answer

Yes. Every fill adjudicates as a claim through your TPA, and member cost share posts to the deductible and out-of-pocket maximum. That is the line separating this from an off-benefit card.

Question 11

How is this different from a manufacturer cash card or a drug-specific HRA?

Accepted Answer

Both sit outside the plan. Neither adjudicates, so cost share does not accumulate and the plan has no record of what was actually paid. A general-purpose HRA also disqualifies anyone eligible for it from contributing to an HSA, regardless of whether they use it.

Question 12

Doesn't an HRA let us fund only the employees who need it?

Accepted Answer

Possibly, depending on design. Note that the class-based flexibility often cited comes from ICHRA rules, which govern individual-market coverage, not a group HRA running alongside a self-funded plan. The two are frequently conflated. Either way, the adjudication gap and the HSA consequence remain.

Question 13

How fast can we start?

Accepted Answer

There is no open enrollment requirement and nothing to buy. Once configuration is complete, savings begin as members opt in and scripts start routing.

Your plan pays less.Your members pay nothing.

So what's the catch?There isn't one.
Here's the math.

“What drugs do you have?”Enough to save on most scripts today. More every month.

Members opt inbecause it costs them nothing.

Assessed in real time,adjudicated on benefit.

We work alongside your PBM.

Transparency looks backward.Fiduciary duty is exercised in real time.

Funding the drugis not the same as covering it.

You are not choosing a vendor.You are turning on a neutral pipeline.

The savings start when you route.So does the record.

The market is movingto ApalyRx.

The questions we hear most.

From our resources.

Wherever you sit in the prescription,the lowest price should win.

	Employer-funded card	General-purpose HRA	ApalyRx on benefit
Operates on benefit	No	No	Yes
Counts toward deductible and MOOP	No	No	Yes
Preserves HSA eligibility for HDHP members	Yes	No	Yes
Compliant with manufacturer terms	No	No	Yes
Not taxable to the member	No	Yes	Yes
Plan sees what was actually paid	No	No	Yes
Fiduciary-defensible record	No	No	Yes