Prime Therapeutics Presents Real-world Evidence-based Research

Specialty drugs are focus of AMCP poster presentations

October 10, 2022

EAGAN, Minn. – Leading pharmacy benefit manager (PBM) Prime Therapeutics LLC (Prime) used its integrated medical and pharmacy claims data to evaluate the real-world evidence in specialty medicine claims. Studies from these analyses will be presented at the Academy of Managed Care Pharmacy (AMCP) Nexus meeting Oct. 11-14, 2022, in National Harbor, MD.

“It is imperative that Prime understands the value of specialty medications as it relates to the total cost of health care, and shares that knowledge with our health plan clients,” said Patrick Gleason, PharmD, assistant vice president for health outcomes at Prime. “Specialty drugs continue to drive drug trend. Understanding factors associated with high-cost drug therapy use, real-world specialty drug cost-effectiveness, biosimilar conversion programs successfulness, and likelihood members with a specialty condition will remain enrolled all contribute to the development of appropriate member programs and help clients manage costs for themselves and their employer groups.”

Breast cancer predictive modeling optimizes drug therapy

Among commercially insured plans in the study, one in 20 members with actively treated breast cancer were predicted to have more than $100,000 in drug therapy costs annually. With a successful “drug super spender” predictive model previously developed, Prime applied its predictive modeling approach integrating medical and pharmacy claims data to identify members with higher costs for breast cancer treatment to target those for drug therapy optimization such as those who could be switched to a biosimilar or other lower cost therapies.

High-cost breast cancer member indicators included in the model include member demographics, financial risk scores, diagnosis codes, breast cancer type, previous spending, drug utilization, and timing of surgery relative to drug therapy. The key predictors identified included previous total drug spend in the past 12 months, use of drugs associated with HER2-positive status, metastases indicators, and hormone receptor positive or negative diagnoses.

CFTR therapy direct costs exceed direct medical care cost reductions

For this bronze award-winning study, Prime utilized real-world, integrated pharmacy and medical data to identify a statistically significant reduction in pulmonary exacerbation events, inpatient hospitalization, emergency department visits and medical costs in the six months following the beginning of cystic fibrosis transmembrane conductance regulator (CFTR) treatment.

Despite this reduction, there was a $25,593 average increase per utilizer per month in pharmacy benefit costs that were not offset by the $3,347 average savings per utilizer per month in medical benefit costs. Among new initiators of CFTR therapy with no previous CFTR treatment history, total cost of care increased 3-fold despite clinically meaningful reductions in health resource utilization, pulmonary exacerbations and total medical benefit spend. For every $7.64 in new pharmacy benefit spend, there was $1 in medical benefit cost avoided.

Real-world infliximab biosimilar adoption strategy a success

Biosimilars have seen increased adoption in recent years, promising greater competition and lower pricing than their reference drugs. Prime and Regence Health Plans stand for use of biosimilar products in place of the reference drug in most clinical circumstances.

Regence achieved greater than 90% infliximab adoption and an associated $.40-.60 per member per month (PMPM) estimated savings by preferring one of the three infliximab biosimilars currently available. To drive early adoption, Regence used numerous communication channels to reach providers and members, a clinically appropriate medical policy and a prior authorization management plan.

Collaboration between Regence and Prime’s MedDrive program enabled optimization of manufacturer relationships and analytics and provided a platform to discuss and share important learnings among Prime’s health plan clients.

Members with chronic illness showed higher insurance enrollment

The commercial health insurance market has a high enrollee turnover which disrupts the continuity of care for members and creates challenges for insurers in managing the health of enrollee populations.1 This large commercially insured real-world study followed members for five years and found significantly higher enrollment among both specialty conditions assessed and seven of nine chronic diseases compared to matched members without a chronic disease.

These findings support managed care pharmacy programs to optimize drug therapy and improve medication adherence resulting in future medical event avoidance seen by the insurer.


  1. Fang H, Frean M, Sylwestrzak G, Ukert B Trends in Disenrollment and Reenrollment Within US Commercial Health Insurance Plans, 2006-2018. JAMA Netw Open. 2022;5(2):e220320. Published Feb 1, 2022. doi:10.1001/jamanetworkopen.2022.0320.

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