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Prime’s powerful PBM toolkit — including aggressive negotiating, tight formularies, managed networks and clinical programs — helps you manage rising health care expenses and drive to lowest net cost.

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Industry-leading formulary

Prime’s innovative NetResultsTM formulary focuses on generic and preferred brand-name drugs and drug exclusions to help plans lower their total cost of care. In 2017, savings for commercial lives covered by NetResults ranged from $10 to $14 PMPM.

 

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High-value pharmacy networks

Managed networks are a proven way to help lower pharmacy costs and we offer a wide variety of options. Our options include a Walgreens-anchored network of more than 40,000 pharmacies which features the deepest discounts and most competitive pricing. In 2017, our Walgreens anchored network saved commercial members more than $5 per member per month (PMPM).

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Negotiated savings

We negotiate with manufacturers and pharmacies to get the best savings possible. In 2017, our clients saw nearly $2 billion in savings from competitive rebates, pharmacy maximum allowable cost (MAC) pricing and other negotiated discounts.

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GuidedHealth

Our GuidedHealth® program analyzes pharmacy and medical data to help improve care and lower overall cost of care.  In 2017, GuidedHealth closed gaps in care and adherence —creating more than $375 million in medical cost avoidance and adherence savings.

 

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Utilization management

In 2017, Prime’s efforts to promote appropriate use of medicines approached $2.3 billion in total savings across all three lines of business — commercial, Medicare and Medicaid.

 

 

 

 

 

Fraud, waste, and abuse detection and prevention

In 2017, Prime’s diligent FWA efforts, such as fraud investigations, audits and enhanced credentialing, helped generate client savings of more than $210 million across our commercial, Medicare and Medicaid business lines.

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Medical drug spend management

Managing medical drug spend is more important than ever. Prime has the expertise and tools to help, including:

  • Medical Drug Review helps clients manage utilization of drugs covered and paid under the medical benefit. 
  • Site of Care helps members choose the right location for the safest and most cost-effective care. 
  • Reimbursement Solutions analyzes plans’ medical fee schedules to help uncover opportunities to adjust reimbursement rates. 
  • Medical Claims Edits uses a set of drug-specific guidelines to identify medical claims that are out of line with expected cost, quantity or clinical use.

Facts and figures from Prime internal analysis.