Giving Medicaid the attention it deserves

Prime’s dedicated Medicaid management team makes it its mission to achieve both the lowest drug costs for our Medicaid clients and the highest quality of care for members

August 12, 2019
Medicaid programming is an essential part of a health plan’s portfolio of programs offered in its community. Diversity of a population’s needs, as well as regulatory oversight, demand a unique market-specific focus. Unlike other PBMs, Prime acknowledges this through its dedicated Medicaid General Management team. This team of Medicaid experts, with a combined 80 years of experience, has full oversight of Medicaid programming and client assistance. A dedicated focus allows Prime to better understand the Medicaid marketplace and deliver positive clinical and financial outcomes for clients and their members.

Navigating the maze of Medicaid regulations
Specific Medicaid regulations vary from state to state, but often align around common themes–opioid management, fraud, waste and abuse, and member access, to name a few. Managing these regulations can be a confusing process. Prime, however, has the experience necessary to fully understand these regulations, identify best practices and implement solutions that will work at the local level. This gives clients confidence knowing Prime has their compliance needs met.

Achieving a low drug trend, even with rising drug prices
It’s because of this experience and expertise that, since 2016, Prime has maintained a flat Medicaid drug trend.1 In fact, Prime’s three-year published trend average is 48 percent lower than other Medicaid PBMs.1 In an environment of increasing drug costs, this is a big win. Prime makes this happen using its wide range of well-designed programs and products:

Fraud, waste and abuse programs
Drug manufacturer rebates (where allowed)
Push for more use of generics
Negotiated savings
Clinical programing
Compare this to the competition: Prime’s average three-year Medicaid drug trend was 48 percent lower than top competitors. Utilization has been mostly consistent, so the big difference was in unit costs.3

Total drug management is how we do business
Prime sees the big picture, which is why we believe it is important to align both the medical and pharmacy benefits to help manage use, costs and experiences. This total drug management approach helps our Medicaid clients achieve the lowest possible drug costs.

Prime’s commitment to Medicaid members leads to savings
At Prime, our focus is on helping members get the medicine they need to feel better and live well. We do this, in part, by analyzing, planning and negotiating to be sure our Medicaid members have access to affordable drugs. We also offer products and services that help these members stay on treatment. This helps them stay healthy while also cutting costs for clients.2

2018 value — Prime has delivered:

More than $288 million in Medicaid savings; more than $9.3 million through FWA initiatives
15.2 percent lower average price per script than national managed care organization average
Generic utilization rate of 87.4 percent
These numbers demonstrate Prime’s commitment to Medicaid and show how we help our Medicaid clients achieve the lowest possible drug costs, while also providing the highest possible quality of care.

1. Prime internal data 2019

2. CMS.gov Medicaid Drug Spending Dashboard

3. Based on study of Prime Therapeutics and other Medicaid competitors published reporting trend 2016-2018.

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