Prime continues to build its predictive modeling tool

It points to Medicare members whose medication use could improve

December 2, 2019
Supporting adherence used to be black and white. A member is either taking medications or not. Most of the time, we measure it by tracking the timing of a member’s claims: the percentage of days in a month that are covered by the pills a person has on hand. It’s called the proportion of days covered (PDC) methodology.

We now have an evolved tool that can do more. Our predictive model helps us identify the traits of a person that is likely to stop being adherent in the near future. That means we can intervene earlier, even before the person has stopped taking the medication. Our pharmacists can help remove common barriers, which helps keep the person on their treatment plan.

GuidedHealth’s® Smart Adherence program focused on Medicare members

The Centers for Medicare & Medicaid Services (CMS) focuses on adherence when it evaluates health plans’ quality. Two-thirds of Medicare members have at least two or more chronic conditions requiring treatment with medications. Non-adherence for this group accounts for more than 90 percent of Medicare health care spend.1,2

Better adherence to medicines in the diabetes, high blood pressure and high cholesterol drug categories can improve the Star ratings CMS gives to a plan. Higher Star ratings helps the plan increase its enrollment and receive CMS bonus payments.

AMCP gave the gold to Prime’s predictive modeling research 

Prime presented the Medicare Smart Adherence program in October at the Academy of Managed Care Pharmacy (AMCP) national meeting. The study showed Medicare members’ adherence to their medicines improved following proactive phone calls from pharmacists.

The predictive model helped identify members who would benefit the most from the call. The model evaluated more than 400 variables including:

  • Pharmacy claims history
  • Sociodemographics
  • Benefit design
  • Severity of member’s illness, and
  • Travel distance from a member’s home to their pharmacy

The pharmacist call educated members on the importance of taking their medication as prescribed and provided resources to help overcome barriers that may contribute to stopping their medication. Members receiving a pharmacist call had statistically significant higher odds of adherence from 2017 to 2018, compared to the control group that did not receive a call.

The increased medication use resulted in estimated Star rating increases of about 1.07 percentage points among the three disease states. A single percentage point increase can raise a 3 Star rating to 4, or a 4 to a 5 Star rating.

AMCP recognized the research with a gold ribbon.

Prime has several adherence programs that are clinically sound and validated by research. They build on the strengths of those that came before them.

Missed refill program improved refills and adherence 

In 2016, Prime launched its innovative missed refill program for Medicare. This program identifies members as early as possible after a prescription has lapsed. The outreach program focuses on the three Star rated drug categories: high cholesterol, high blood pressure and diabetes.

The reminders start with an automated phone call. If the refill claims do not come through by the following Monday, then Prime sends a personalized, first class letter. The letter includes the name of the drug and offers help getting it refilled.

Medication refills increased 1.5 percentage points and showed an 8 percent higher refill rate among members who received the two-touch intervention compared to those who did not. The missed refill program delivered a statistically significant 1 to 2 percent increase in adherence for the three combined Star drug categories. And at the end of the year, those members held on to an improved adherence rate. Validated, proven results.

The Star formularies lowered member cost share

In 2014, our goal was to impact adherence by lowering member cost share on the drugs impacting Star Ratings. We created formularies with specific generic drugs that plans could offer at a very low member copay. These formularies targeted members for whom cost was a barrier to adherence.

Most Medicare formularies have five tiers. Tiers one and two, which have the lowest copays, are often designated for generics. CMS allows for a select care tier that can be used to offer a no — or very low — copay for specific medicines. This approach can be used to encourage adherence.

We took Medicare’s five-tier formularies and added this extra sixth tier. In 2015, we launched the new Star formulary with two of our Blue Plan clients. Adherence improved right away. In analyzing the data, we could see that members with lowered cost share for generic drugs in the Star formulary saw overall adherence improve by 1.4 percentage points when compared to members not in the program.

Recognition for innovative, effective benefit designs

Innovative benefit designs. Built and piloted in concert with Blue Plans. Validated by peer- reviewed research.

  • The Star formulary helps lower cost share to members.
  • The missed refill program gives members a faster reminder when a prescription has lapsed.
  • And Smart Adherence identifies which members are likely to have adherence challenges down the road for pharmacist call outreach.

Prime recently announced that a record 17 of its Medicare contracts earned quality bonus payments. This is based on 2020 Star Ratings recently released by the CMS.

Twenty-one of Prime’s 33 Medicare Advantage Prescription Drug (MAPD) contracts that received ratings during the 2018 measurement period earned 4 or more Stars on the Part D side. That represents approximately 86 percent of Prime’s MAPD membership.

Prime will continue to work with our Blue Plan clients to provide innovative products and services that deliver health care solutions.


1 “The Cost of Not Taking Your Medicine.” By Jane E. Brody April 17, 2017. New York Times. © 2018 The New York Times Company. Accessed at:

2 “How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program?” Lloyd, Jennifer T., et. al. Medical Care. March 2019 – Vol. 57 – Issue 3 – p 218–224. doi:10.1097/MLR.0000000000001067. Accessed at:

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