How Prime leverages data, collaboration and unique solutions to reduce drug costs

Whether you’ve seen it in the news or experienced it in your own life, the U.S. is engaged in an ongoing conversation around rising drug costs. And pharmacy benefit managers (PBMs) like Prime are playing an increasingly important role in combatting this trend, implementing approaches to lower drug costs while improving patient care and satisfaction.

Prime Therapeutics’ goal is to provide each person with the right medicine at the right place and in the most cost-effective way. It’s part of our Quadruple Aim: Improving member experience and population health, reducing cost of care and engaging the health care team.

We achieve this through actionable insights from health plan data, leveraging specialty expertise, better connecting physicians, pharmacists and patients in a streamlined care team, and using transparency around rebates.

Leveraging strategic partnerships and data to analyze costs

Our partnership with 19 Blue Plans provides medical and pharmacy data that we leverage to benefit patient outcomes. We use technology to analyze data to locate high-cost members and suggest interventions that can save up to thousands of dollars for health plans and patients. Specialty-trained pharmacists, in partnership with Blue Plans, conduct personalized outreach recommending alternatives that improve patient outcomes and can reduce costs. This helps ensure members use their medication in a safe, cost-effective way.

For example, Prime’s HighTouchRx® used analytic intelligence to identify a member taking a large number of expensive, low-strength tablets for cancer treatment. Our pharmacist connected with the provider to consolidate the doses into fewer, higher-dose tablets and reached out to the member to arrange for a new prescription. The patient began to take fewer pills resulting in better care at a lower cost, and the health plan saved $30,000 by dispensing fewer pills.

Addressing specialty drug spend increases with Magellan Rx

Our recent agreement to acquire of Magellan Rx, which provides Medicaid and state pharmacy program administrative solutions, will enhance Prime’s ability to lower drug costs and improve member health outcomes post-closing. We’ve seen specialty drug spend increase dramatically over the past decade – it now accounts for half of total pharmacy costs¹. By building on Prime’s strong foundation of pharmacy benefit capabilities with Magellan Rx’s medical specialty portfolio, we’ll employ a next-generation specialty management strategy with an eye on mitigating specialty spend and trend, while improving the member and provider experience. This integrated specialty management model will aim to lower total drug expense and improve clinical outcomes.

Delivering cost-effective, convenient care through our integrated approach

We’ve also driven cost savings through our unique integration model. For example, our Integrated Rx – Oncology product leverages our channel-independent approach, helping patients receive their cancer medications in a way most convenient to them. That could be directly from their oncologist’s clinic or at an affiliated hospital pharmacy instead of through a central specialty fill pharmacy. This approach facilitates a stronger connection within a patient’s care team – the physician and pharmacist – making it easier to collaborate, while maintaining the quality, effectiveness, and safety of medications and treatment.

Initial pilot results showed improved medication adherence and care management for Prime and participating Blue plan members as a result of the integrated pharmacy-provider model. Some patients were able to receive treatment up to two days faster. The integrated pharmacies also reduced waste by 40%.

Focusing on transparency

Today, most insurance providers contract with PBMs to handle prescription drug claims. PBMs establish a list of drugs called formularies to guide patients to the most appropriate medicines. Including a drug on a formulary can drive higher use. This is intentional as each medication has been evaluated to offer a significant clinical advantage by our Pharmacy and Therapeutic (P&T) committee after reviewing the latest clinical research and best practice clinical guidelines from respected national professional societies. Managing formularies helps PBMs negotiate volume discounts in the form of rebates that get passed along to the health plans and members to lower total benefit costs.

Prime’s operating model, which differs from other PBMs, is to earn revenue by charging an administrative fee so we can return any rebates to our health plan clients through direct pass-through. The transparency in how we manage our funds is verified through our Blue Plan owners’ oversight into our board of directors and management forums.

Leveraging our nationwide pool of data, relying on close physician-pharmacist collaboration, and prioritizing transparency are now status quo for our team. It’s how we’re expanding our ability to do great things for the members we serve while helping reduce the impact of drug pricing on the marketplace. As the discussion around drug costs continues, we look forward to developing meaningful solutions that will help control the cost of drugs and improve the health care system.

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1. IQVIA, 2021