Driving Medicaid dollars to do more

Dedicated Medicaid teams drive value programming for Prime clients

April 21, 2020

Today, more than 70 million Americans are enrolled in Medicaid plans.¹ Medicaid represents $1 out of every $6 spent on health care in the United States — and that number is growing.² At Prime Therapeutics (Prime), we have a team dedicated to understanding Medicaid in markets across the country. We know the state regulations. We know the market needs. And we have the right tools to lower cost of care and provide better health outcomes.

Better Medicaid management means seeing the big picture

Our total drug management approach starts with our superior partnership with Blue Cross and Blue Shield (Blue) Plans. We don’t just work for Blue Plans, we’re actually owned by them. This makes Prime the Blue Plan solution, and we work together to find more ways to achieve the lowest net drug costs.

  • 100% client satisfaction scores for last two years³
  • Over $3.1 million network savings in 2019

Our total drug management approach also includes consumer-centric innovations, like our missed refill and tailored utilization management programs, controlled substance management and GuidedHealth® to help promote adherence and create a better member experience, something we understand well.

Through in-depth research and interviews with Medicaid experts and members, our Medicaid management team has focused programming on the Medicaid member experience, creating distinct member profiles and journeys that identify the barriers they face. We use these profiles and journeys to ensure the programs we create address barriers to care and meet member’s diverse needs.

In 2019, Prime’s Medicaid clients achieved:

  • $208 million savings from utilization management programs
  • More than $20 million in savings using GuidedHealth® adherence program
  • 7.6% fewer opioid claims from 2018 to 2019
  • $11.1 million in fraud, waste and abuse savings

Specialty drug management: Here, our consumer-centric innovation helped us create split fill, a program that curbs waste and ensures appropriate drug use when members can’t tolerate high-cost therapies. Another example is reimbursement solutions, which encourage solutions that support physicians’ use of lower-cost, clinically appropriate drugs.

Prime’s study on Medicaid adherence struck gold. A gold medal, that is.

To prove our commitment to the Medicaid market, Prime conducted a pilot on the impact of missed refills among Medicaid members. As part of Prime’s missed refill program, detailed in our Missed Refill Blue paper, members with missed refills were sent a letter explaining the importance of taking their medicines — a tactic that, when applied to Medicaid members, has faced skepticism within the industry. Our study, however, showed an improved refill rate, as well as a less-than-1% return rate for the missed fill letters. The pilot was a success — so much so that it received gold medal recognition from the Academy of Managed Care Pharmacy (AMCP) in 2019.

Every state has regulations. Prime understands the complexity.

Seeing the big picture also requires regulatory expertise to understand the unique needs of each state market — a key strength of our Medicaid management team. Along with our Government Affairs team, they’re able to navigate regulations and influence policies that may affect a state’s Medicaid programs and the members they serve. Our refined strategies and knowledge are what make it possible.

With all these advantages, what’s our goal?

At Prime, we’re transforming how Medicaid is viewed within the pharmacy benefit management industry. We’re doing this through research and collaboration with our Blue partners, through outreach and intervention with Medicaid members, and by understanding the barriers they face in their daily lives. It’s comprehensive Medicaid management, from a team that’s dedicated to helping lower costs and improving health outcomes.


  1. December 2019 Medicaid & CHIP Enrollment Data Highlights. Medicaid.gov. Center for Medicare and Medicaid Services. Accessed at: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
  2. “Medicaid Financing: The Basics,” by Robin Rudowitz, Kendal Orgera, and Elizabeth Hinton. Mar 21, 2019. Kaiser Family Foundation. Executive Summary. Accessed at: https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/view/print/
  3. Prime Client Satisfaction Surveys

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