Prime Therapeutics launches Specialty Monitor™ to deliver total drug management insights

EAGAN, Minn. – Prime Therapeutics LLC (Prime), a pharmacy benefit manager (PBM) serving 23 Blue Cross and Blue Shield plans nationally, recently launched Specialty Monitor™ powered by Artemetrx, a first-of-its-kind, integrated data solution that provides an unparalleled knowledge option to Prime and its health plans. Specialty Monitor delivers to clients their specific medical and pharmacy benefits insights – using an automated method that’s different from other PBMs – to manage the rapid rise in the use of specialty drugs and high cost spend.

Prescription drug spending is approaching 30 percent of total health care costs and specialty drugs will represent 60 percent of Prime’s total drug expenses by 2021.¹ In 2017, 57 percent of specialty drugs were covered on the medical benefit, and specialty drugs for complicated illnesses such as autoimmune conditions, drove most of the total cost of care.¹ Several innovative drug therapies have been introduced in recent years, including treatments that cure disease; however, they come at a very high cost, many ranging from $50,000 to $300,000 or more annually. While these costly treatments contribute to increased spend for a small group of individuals, when combined with a robust specialty drug pipeline, they are contributing to unsustainable health plan costs.

Specialty Monitor gives Prime clients self-service access to their plan’s specialty drug data – both medical and pharmacy benefits – to inform smart business decisions and improve the care for their members. It provides insights through clients’ reports, dashboards and tools that deliver an unparalleled level of data and eliminates previous manual processes. The user-friendly, web-based tool is dynamic in that it analyzes drug use, costs and trends over time, by population or individual. It also shows cost and use breakdown for sites of care (moving from hospital to lower cost home infusion) – revealing opportunities for drug administration that might be less expensive – as well as identifying the top drugs by spend and by category, and benchmarks against similar populations.

Prime’s unique connection to its Blue plan clients provides access to medical benefits data, which, combined with pharmacy data, helps tell the complete story of the total cost to treat individuals who use specialty drugs.

On initial rollout to 10 health plans with nearly 10 million members and annual combined specialty drug costs totaling approximately $7 billion, Specialty Monitor has provided insights with the potential to translate into hundreds of millions of dollars in savings. For example, Specialty Monitor detected duplicate high-cost therapy prescribed for individuals being treated for hereditary angioedema (HAE), identifying a $1 million savings opportunity. Clients may leverage the tool’s actionable data to implement high-touch case management programs for individuals with challenging conditions to produce cost savings, while helping to ensure appropriate medication use and improve health outcomes.

In addition to duplications or site of care, Specialty Monitor will also identify possible savings opportunities if a member were to switch from a high-cost drug to a lower-cost alternative that’s equally safe and effective. Plus, it can identify and flag providers with higher than average reimbursement and administration fees. Once these savings opportunities are identified, health plans can take a tailored approach to managing total care such as focusing on claims with high dollar savings and low member disruption.

“As a PBM that’s laser-focused on total drug management, Prime believes it’s absolutely critical today to be able to analyze both medical and pharmacy data to understand the total cost of treating members. That insight can predict health outcomes and is powerful in our ability to hold down drug costs for everyone,” said Jonathan Gavras, M.D., senior vice president and chief medical officer for Prime. “We partnered with Artemetrx to create an impactful solution, providing drilled-down data that’s easily accessible and enables us to work with our clients to make data-driven decisions on how to improve drug use and lower costs.”

“Specialty Monitor leverages the Artemetrx platform to transform data into intelligence, powering improved management of high-cost specialty drugs across the pharmacy and medical benefits,” said Kevin Host, president and COO for Pharmaceutical Strategies Group® (PSG). “Prime’s commitment to empower clients with these actionable insights is unique among PBMs and enables efficient and holistic total cost of care management for health plans.”

The role of predictive analytics – leveraging historical data to forecast trend and cost savings – is emerging in improving patient outcomes.² Specialty Monitor is one way Prime leverages large claims datasets to identify patterns that are then used to create and deliver meaningful savings opportunities and clinical programs for members with a wide range of conditions.

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1. Based on internal Prime analysis, 2017.
2. HealthITAnalytics. 10 High-Value Use Cases for Predictive Analytics in Healthcare. Available at: https://healthitanalytics.com/news/10-high-value-use-cases-for-predictive-analytics-in-healthcare. Accessed Feb. 12, 2019.