Capital BlueCross advances its precision drug access & cost reduction initiatives with new pharmacy benefit manager

HARRISBURG, Pa. – As drug costs rise and new therapies bring both life-saving promise and unprecedented expense, Capital BlueCross remains committed to providing its members with the drugs they need at a price they can afford, while also driving innovation within the drug industry to facilitate better health outcomes.

Starting in 2020, Capital BlueCross is working with a new pharmacy benefit manager, Prime Therapeutics, LLC (Prime), to help advance these goals through collaboration on:

• Precision drug access – Healthcare is no longer only preventive or diagnostic. Doctors can now customize care based on patients’ specific biologic needs. Capital BlueCross aims to ensure its members have access to the most appropriate drug therapies in order to achieve the best and most efficient clinical outcomes.
• Integrated management of health outcomes – By integrating medical and pharmacy coverage with advanced disease management programs, employers can generate significant savings by empowering healthier, informed employees to incur fewer hospitalizations, reduce emergency room visits, and better adhere to their medication plans.
• Supply chain management – Prime actively manages the pharmaceutical distribution process in order to drive safe, rapid, and cost-effective drug delivery. Supply chain management can now be influenced with the purchasing power of more than 100 million individuals nationwide.
• Improving health by using actionable analytics – With more than 28 million members nationwide generating nearly 400 million healthcare claims annually, Prime offers a powerful analytics engine to identify and predict trends, build award-winning formularies, and deploy standards to enhance safety and access to new or evolving therapies. This analytics engine, coupled with the advanced analytic capabilities of Geneia’s Theon platform, will yield an integrated approach to managing the total cost of care.
• Striving to eliminate fraud, waste, and abuse – The insights derived from Prime and Geneia help identify and act on fraud, waste, and abuse across pharmacies, providers, and patients, resulting in millions of dollars in savings.
• Enhanced member experience – Healthcare consumers increasingly want choice and convenience. With this collaboration, members have access to an extensive network and delivery options, 24/7 member services, advanced clinical resources to help members manage medical conditions, and “My Rx Guide,” a one-on-one medication consultation for designated members with complex needs.

“We are in an era of drug revolution,” explained Peter Mikhail, vice president of Pharmacy Operations for Capital BlueCross.

“This is an exciting time — as science is discovering cures to devastating diseases, we will see the dramatic, life-saving results. Within that landscape, it is increasingly important to provide access to the many medicines helping our members and their families, to promote safe utilization, and to manage costs.

“With some of the best scientists in the industry, association with world-renowned research institutions, innovation and speed to market, we know Prime Therapeutics will prove to be a differentiating factor in helping us achieve our goals.”

Capital BlueCross will be the only health plan in Pennsylvania to offer the benefits of Prime Therapeutics to its members.

“We are delighted that Capital BlueCross has chosen Prime as its full-service pharmacy benefit manager,” said Ken Paulus, president and CEO at Prime. “As health plans, employer groups, and members continue to be challenged by unsustainable drug costs, we are committed to finding innovative solutions to help make medicines more affordable. Year over year, we’ve delivered among the lowest drug cost trends, evidence of our effectiveness in driving lower costs and improving health outcomes.”

Capital BlueCross and Prime Therapeutics entered into a three-year, full-service agreement effective Jan. 1 that covers commercial and individual market members, as well as members enrolled in Capital BlueCross’ Medicare and Children’s Health Insurance Program (CHIP). It expands the relationship between the two companies, as Prime Therapeutics began providing specialty drug management services to Capital BlueCross’ commercial and Medicare members last year.