Not tomorrow. Today. Putting more value in value-based contracts

Prime has innovative value-based contracts that focus on health outcomes

October 30, 2020

Real-world data is the cornerstone of Prime’s value-based contracting strategy.

Value is the foundation of Prime’s total drug management strategy.
Our health outcomes research shows us which drugs provide the highest value relative to their cost. That helps us build value-based agreements that work to improve the quality of care for members while also reducing costs.

Prime is a thought leaderPrime is a thought leader in building sophisticated, precise and useful value-based contracts.¹

In May, an article in Forbes noted that pharmaceutical value-based contracting (VBC) in the United States was underwhelming. Industry leaders keep projecting broader use of VBCs further into the future.2 Access to the huge volumes of clinical, medical and pharmacy data needed — and the ability to share and analyze this data is a stumbling block.

Prime addresses this problem through its:

  • Access to pharmacy data
  • Access to regular medical data streams from our health plan clients
  • Experience in analyzing integrated pharmacy and medical data
  • Data scientists experienced with working with clinical data
  • History of published, ground-breaking research

We are reaping the value of VBCs for our clients, today. We have VBCs in sixty percent of the top-selling drug categories.¹ Our VBCs have two broad areas of focus, depending on the drug and the therapeutic category.

First, duration of use, adherence, or persistency. These VBCs are more common. For Prime, they yield valuable member-level data that can help determine the right fit. And they provide learning opportunities that can be applied to clinical programs and future contracts.

Second, clinical outcomes, total cost of care or price caps. It is in these VBCs where Prime’s unique skills come into play:

  • Our ability to integrate medical and pharmacy claims
  • Our experience with medical claims outcomes data
  • Our rich history of published data on the impact of drug costs to total cost of care and more

Many VBCs are designed to measure duration of use

This isn’t just about tracking refills. Our analytics go far beyond that.

Diabetes VBC: Victoza® (liraglutide) from Novo Nordisk; Persistency of use

More than 10 percent of people in the United States have diabetes.3 As an example of persistency of use, Prime has a VBC with Novo Nordisk for the Type 2 diabetes drug Victoza® (liraglutide). The VBC aligns with Prime’s strategy, which focuses on controlling costs for members. Drugs used to treat diabetes make up a large portion of overall drug costs for health plan clients. Members who stay adherent to their diabetes drug therapy have lower medical costs. But drugs have side effects. And patients have other challenges with taking their diabetes drugs. This means that medication persistency does not always match what is seen in clinical trials, leading to a lower overall value.

Our collaboration with Novo Nordisk gives us valuable data and analytics to help improve patient health and support affordability. The more we understand about adherence to diabetes medications, the more we can help patients prevent more serious, future health issues.

Prime continues its research on diabetes cost of care.4 Prime has more VBCs that, along with other strategies, help clients manage diabetes trends.5

Multiple Sclerosis VBC: Biogen* portfolio of products; discontinuation.

Members with multiple sclerosis have expenses eight times higher than members without MS. Eighty percent of these costs are from expensive disease-modifying drugs.6 Prime has one VBC with Biogen that covers several disease-modifying drugs (DMDs):

  • Avonex® (interferon beta-1a)
  • Plegridy® (peginterferon beta-1a)
  • Tysabri® (natalizumab)

Prime’s ability to access to both pharmacy and medical claims is important because these drugs may be covered under either benefit. Prime’s VBC with Biogen looks at patients just starting on these drugs and pays out at an aggregate level for patients who discontinue use.

DMD adherence is associated with a decrease in the incidence of relapses, which is the goal of MS treatment. But the use of DMDs is not offset by a reduction in medical expenses, at least in the short term.6,7 Prime has conducted research that shows the price to value gap for MS drugs.8 Our VBCs for MS drugs work toward closing this gap.

VBCs tied to clinical outcomes and cost of care

Diabetes with cardiovascular disease (CV): Jardiance® portfolio from Boehringer Ingelheim; total cost of care compared to a control group

Another unique VBC that focused on patients with diabetes and cardiovascular disease (CV) is Boehringer Ingelheim’s Jardiance product portfolio:

  • Jardiance empagliflozin
  • Synjardy® (empagliflozin, metformin hydrochloride)
  • Glyxambi® (empagliflozin, linagliptin

Prime has conducted research that shows that half of the medical costs of patients with diabetes are not diabetes-related.9 They are costs from treating comorbid conditions, including high blood pressure, high cholesterol and CV disease. CV disease made up the largest category of costs under the medical benefit. Boehringer Ingelheim is confident in its products’ ability to reduce CV-related costs.

>This VBC compared members with CV using these products to a control group of members with CV on other diabetes drugs. This also leveraged Prime’s ability to integrate pharmacy and medical data.

If the total cost of care for members using a Jardiance drug was higher than those using other diabetes drugs, Boehringer Ingelheim would provide additional value to Prime’s clients.

Heart failure: Entresto® (sacubitril-valsartan) from Novartis AG; total cost of care

Prime won a platinum award from the Academy of Managed Care Pharmacists (AMCP) for its research on Entresto (sacubitril-valsartan or sac-val). The research was shown at a virtual podium presentation at AMCP on October 21, 2020.10 Sac-val is approved to treat heart failure with reduced ejection fraction (HFrEF) and been proven to reduce mortality and hospitalizations.10 Prime identified and followed 658 members newly starting and adherent for a year on sac-val. We compared their costs to the year prior. These members had a $6.7 million lower cost of care while on sac-val compared to the year prior.

These significant real-world findings, along with a pharmaceutical manufacturer value-based contract, clinical trial data and clinical guidelines, resulted in the removal of the sac-val prior authorization.

Agreements with Alnylam Pharmaceuticals

Prime has negotiated value-based agreements with Alnylam Pharmaceuticals for two orphan drugs:

  • Onpatrro® (patisiran) for the treatment of hereditary amyloid transthyretin-mediated (hATTR) amyloidosis
  • Givlaari® (givosiran) for the treatment of acute hepatic porphyria (AHP).

These therapies represent the first two innovative drugs developed based on RNA interference (RNAi). They are the result of nearly twenty years of research conducted by Alnylam.11 Both Onpattro and Givlaari came to the market with some unknowns – related to the prevalence of the rare diseases being treated, and the alignment of real-world outcomes to those observed in clinical trials. Value-based agreements structured to address these risks may help to manage the costs of these drugs:

  • List price for Onpattro is $445,000/PMPY
  • List price for Givlaari is $575,000/PMPY

Even with a value-based agreement, if the initial price is higher than the drug’s price to value, there is still some negotiating to do in a value-based contract. Both Onpattro and Givlaari fall under the medical benefit. Their performance to the contract parameters will need to be assessed against both medical and pharmacy claims.

Onpattro treats patients with polyneuropathy caused by the rare condition hATTR amyloidosis, which is caused by the buildup of amyloid deposits in the body. Givlaari treats patients affected by AHP, a family of ultra-rare, genetic diseases that are caused by an enzyme deficiency in the liver.

Prime is implementing the future of VBCs, today

Our VBCs are designed to demonstrate the value of the selected medicine(s) when taken appropriately. They show the impact of drug therapies on overall total cost of care. The contracts support specific outcome goals like adherence, reduced ER visits, hospitalizations and more. In this way, the contracts work to align payers, employers, members and providers on improving health outcomes.

In the past 18 months, Prime has held more than 100 VBC discussions with pharma. We continue to see a lot of potential for growth in VBCs. We see the value they can bring to the entire health care system.

Sometime in the future, other PBMs might be able to do what we can do now with VBCs. Someone might develop a data application that lets other PBMs have the same kind of medical and pharmacy data access that we have today.

But for now, I know that what we are able to do with integrated medical and pharmacy data — because of our relationship with our Blue Plan owners — is unique.


  1. Prime Therapeutics, Eli Lilly support patient-centered value-based arrangements for prescription drugs, July 28, 2020. Accessed at:
  2. Use Of Value-Based Contracting For Pharmaceuticals Is Underwhelming. By Joshua Cohen, May 1, 2020. Forbes. Accessed at:
  3. Diabetes Statistics. 2018-2020 Diabetes Research Institute Foundation Accessed at:,the%20population%20%2D%20had%20diagnosed%20diabetes.
  4. Building Prime’s knowledge base about members with diabetes. March 19, 2019. Prime Insights. Accessed at:
  5. Assigning the right value to value-based insurance design. March 29, 2018. Prime Insights. Accessed at:
  6. Multiple sclerosis (MS): a look at cost of care, disease-modifying drugs (DMDs) adherence and relapse rates. (A summary of two studies for AMCP). Prime Insights. July 2018. Accessed at:
  7. Noyes K, et al. Cost-effectiveness of disease-modifying therapy for multiple sclerosis: A population-based study. Neurology 2011;77:355-363. Accessed at:
  8. Mind the gap: Using a drug’s price-to-value calculation, by Pat Gleason. December 19, 2019. Prime Insights. Accessed at:
  9. Insights with Impact: managing diabetes costs with data. Prime Insights. Accessed at:
  10. Burke, JP; Sahli, B; Gleason, PP. Sacubitril-valsartan real-world assessment of total cost of care and resource utilization pre/post Initiation among commercially insured members with reduced ejection fraction heart failure. AMCP Nexus, October 20, 2020, Accessed at:
  11. Most innovative companies: Alnylam Pharmaceuticals. 2019 Top 50 Biotech. Fast Company & Inc © 2020. Accessed at:

*Recent market events have changed product emphasis in Biogen’s MS portfolio (generic classifications changing market positions between Tecfidera® and Vumerity®)

Value-Based Contracting Blue Paper

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