Prime offers real-time benefit check tool to deliver drug cost transparency at point of care, simplify prescription filling

Shopping for medicines isn’t like buying a TV at a retail store, where prices are plainly displayed so consumers can compare their features and cost. It’s common to receive a written prescription from a doctor, only to learn upon arrival at the pharmacy counter that the medication carries a sky-high cost. With drug prices sometimes equivalent to the cost of a TV or other expensive electronics, it can leave consumers feeling frustrated and ill-equipped to make in-the-moment decisions. These decisions can potentially have consequences that impact a consumer’s health and their wallet.

According to a recent Kaiser Family Foundation poll, nearly one in four Americans taking prescription drugs say it’s difficult to afford their medicines, and of those surveyed, 29 percent did not fill prescription medicine as directed because of the cost.

As the national dialogue remains laser focused on high drug list prices, legislators recently proposed bipartisan bills related to greater drug price transparency. And beginning Jan. 1, 2021, the Centers for Medicare & Medicaid Services (CMS) will require insurers that offer Medicare Part D health benefits to use an electronic drug cost and health benefit comparison tool that’s compatible with at least one electronic health records (EHR) system.

Prime Therapeutics understands that consumers care about ways to curb rising drug costs. That’s why Prime is piloting a tool aimed at putting information at the fingertips of providers and members early in the prescription-filling process. Prime partnered with its health plan client, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ), to implement a real-time benefit check solution. This tool, which uses the e-prescribe part of a provider’s existing electronic health records (HER) system, shows providers their patient’s specific benefit information. Real-time benefit check has direct benefits for members who struggle to afford their medications and thus become less likely to take them as directed, driving up their short- and long-term health care costs.

Real-time benefit check shows the provider alternative drug options that are equally effective, but are a lower cost than the originally selected drug. The tool also highlights a member’s cost share for each alternative drug, enabling prescribers and members to make more informed decisions and utilize use the most cost-effective drug for a member’s specific condition. If the prescriber’s drug selection requires a prior authorization or step therapy – and an alternative is chosen that doesn’t require one or both – the prescribing and filling process can also become more efficient and productive for the patient, prescriber, pharmacy and health plan.

Prime’s real-time benefit check pilot creates an opportunity for commercial and Medicare Advantage members to discuss whether the medications they take are affordable for them and what alternatives may be available at a lower cost. This technology helps providers select the right drug the first time and helps members better manage their drug spend. And, members leave their provider’s office more informed prior to their pharmacy visit. In fact, early learnings from the Horizon BCBSNJ pilot indicate real-time benefit check triggers at least 2,000 lower-cost prescription opportunities each day.

“We’re already seeing some highly engaged providers who appreciate the value of a real-time benefit check tool. Practices have created workflow efficiencies that help achieve member savings,” said Patrick Gill, director of pharmacy programs for Horizon BCBSNJ. “In the fight for greater cost transparency, what sets Horizon BCBSNJ apart is our deep local reach and ability to make meaningful provider connections. We’re committed to working side by side with providers to create efficiencies in the care delivery system. We are constantly running analytics to refine the tool to meet their needs, while ensuring our members get the drugs they need at the most affordable cost.”

“Prime partners with Blue plans to transform health care by delivering tools designed to help prescribers and their patients clearly see prescription savings opportunities and immediately act on them,” said Laura Terry, vice president, marketing and communications at Prime. “Our real-time benefit check solution helps eliminate the sticker shock that’s experienced all too often at the pharmacy. Together with Blue plans, we’ll continue to test and refine innovative cost transparency solutions, keeping their members at the center of all we do.”

Through its superior partnership model, Prime co-innovates with its health plan clients to bring greater drug cost transparency and other solutions to current and emerging marketplace challenges. This pilot is one way Prime is helping create greater transparency into prescription drug pricing. Prime recently launched several pilots with various industry-leading vendors as part of an effort to transform health care delivery and offset high drug prices by equipping all members of the prescription drug chain – from prescriber, to member, to pharmacist – with tools to enact material change. Prime will evaluate results from the real-time benefit check pilot to optimize the program for a future offering to clients.