Prime Therapeutics keeps high drug cost trends at bay: annual trend reports released

EAGAN, Minn. – Clients of Prime Therapeutics LLC (Prime), a leading pharmacy benefit manager (PBM) with more than 28 million members nationally, saved nearly $3.4 billion in 2018 according to the company’s annual drug trend results issued today. These savings are a result of Prime’s drug management offerings across all books of business. Commercial clients saw a 3.3 percent trend, Medicare Part D plans realized a 4.7 percent trend and Medicaid trend was 7.3 percent.

“At a time when the pharmacy industry is undergoing a significant change, our continued focus is to help members get the medicine they need at an affordable cost,” said Jon Gavras, M.D., senior vice president, chief medical officer at Prime. “And we are seeing a shift to models more like Prime’s, where we are aligned with our clients and offer total drug management capabilities.

“As a pharmacy benefit manager, Prime is a critical part of the drug management system to help control the price of prescription drugs,” he said. “Despite increases in utilization and spend, Prime has been consistently able to help lessen the cost burden for health plans and their members.”

All three lines of business saw increases in drug utilization in 2018, particularly among specialty conditions, which was a major contributor to the trend increase. The autoimmune and oral cancer categories both showed double digit increases in utilization across all business lines. High cost autoimmune drugs were approved to treat additional conditions, and increased marketing contributed to this class’s high utilization trend. The oral cancer category trend was driven by increases in both utilization and unit cost.

Prime’s ability to offer a variety of value-added solutions created opportunity for health plans to realize savings:

• NetResults™ formulary – Commercial clients that adopted NetResults, Prime’s innovative formulary that encourages cost-effective generic and preferred brand use, saw a drug trend that was 11 percentage points lower, on average, than clients on other formularies. NetResults yielded a total savings up to $14 net per member per month (PMPM).
• Fraud, waste and abuse (FWA) – Prime’s best-in-class FWA program became the first to take an integrated approach at addressing fraud investigations, audits and enhanced credentialing among prescribers, members and pharmacies. These efforts generated nearly $270 million1 in total savings for Prime clients.
• Clinical programs – Comprehensive clinical programs help members and their doctors address gaps in care, adherence, safety and overuse of medications. One clinical product, GuidedHealth®, yielded a medical cost avoidance of nearly $500 million1 in 2018.
• Utilization management (UM) – Prime’s UM services – including prior authorization, step therapy and quantity limit programs – help clients manage members’ prescription drug use to achieve the best possible health outcomes while controlling costs. In 2018, UM savings exceeded $2.8 billion1 for health plans.
• Hepatitis C medication management – Hepatitis C drugs remained in the top ten drug spend categories, for both commercial and Medicaid populations. However, both business lines saw significant decreases in trend: -49.7 percent in commercial and -38.9 percent in Medicaid. This utilization decreased as a result of Prime’s strategic formulary management approach with health plan clients combined with a decline in the numbers of members requiring treatment.

Commercial clients realized a value of nearly $1.3 billion in incremental negotiated savings, Medicare clients saw $183 million in savings through Prime’s delivery of competitive rebates and pharmacy network savings, and Medicaid clients benefitted from more than $30 million in incremental network savings. Prime’s differentiated business model as a leading PBM allows us to be fully transparent with our clients and provide a full pass through of rebate dollars as a means of controlling overall health care costs and premium rates for members.

“We are dedicated to offering solutions for health plans and members that improve clinical outcomes, and managing total drug spend across both pharmacy and medical benefits,” added Gavras. “We’re consistently innovating and expectations are high – from our health plan clients, members and ourselves. We are evolving to meet the needs of how pharmacy is delivered in the future and will continue to bring the personalized level of service our partners have come to expect from Prime.”

1. Combined commercial, Medicare Part D and Medicaid spring 2019 drug trend report data.