Using an extra tier to add a new adherence tool

Lowered member cost share for generics, adherence up in Medicare

November 7, 2018

Nonadherence (patients not taking their prescribed medicines) is one of the toughest problems we face in health care. Studies show that half of people with chronic conditions do not take their medicines.¹

And we know that people with chronic conditions have poorer health, use more health services and spend more on health care.2 The Centers for Medicare & Medicaid Services (CMS) has a focus on adherence for medicines to treat high blood pressure, high cholesterol and diabetes. These are among the most common of the chronic conditions: one in four U.S. adults has high blood pressure; one in five has high cholesterol, one in eleven has diabetes.²

Improving adherence to treatment plans for these conditions can improve health and reduce costs. CMS includes adherence for these conditions in its Star ratings quality measures for health plans. The higher the adherence of members to medications for these conditions, the higher the health plan’s Star rating.

There are many reasons why adherence is an issue.² Cost can be a big barrier. Between 20 and 30 percent of people don’t even pick up their prescriptions because the out-of-pocket cost is too high.

We created our Star formularies

Prime has solutions that tackle nonadherence from many angles. Three years ago, we set out to improve adherence by lowering member cost share on drugs impacting Star ratings. We specifically looked at medicines that CMS already identified as part of its Star quality program.

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 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. One use can be to encourage adherence.

We took our Medicare’s five-tier formularies and added this extra tier – the sixth tier. We call these our Star formularies.

Capturing data from prescriptions filled outside the system

This benefit design had the potential to bring back members who might be paying cash for their prescriptions at big box stores with $4 generic pricing. Because these cash prescriptions don’t show up in a member’s health records at their health plan, we can’t record that adherence and the member’s health record is incomplete. The $0 to $2 price could be attractive enough to get members to move their prescriptions. (The plan determines the copay – we provide the formulary that supports it.)

Pilot projects provide proof of concept

In 2016, we launched the new Star formulary with two of our Blue Plan clients. We saw adherence improvement right away. Prime’s Health Outcomes team immediately analyzed the data and produced a study for the plans.

Members with lowered cost share for generic drugs in Prime’s Star formulary saw overall adherence improved by 1.4 percentage points when compared to members not in the program.

Prime presented the results of this study at the Pharmacy Quality Alliance, (PQA) Annual Meeting, May 16-18 in Baltimore.

The study showed that adherence improved:

  • 1.5 percentage points for cholesterol drugs (statistically significant)
  • 1.4 percentage points for high blood pressure (statistically significant)
  • 1.4 percentage points for diabetes (not statistically significant due to small group size)
  • $2 cost share worked just as well as a $0 for improving adherence

The Star formulary became a standard option for all of Prime’s Medicare clients from 2017 on – less than two years after concept development.

Why does this matter?

Helping patients to take their needed medicines keeps them healthier. Also, improving adherence helps plans to improve their overall Star quality rating. The difference between a 3-Star rating and a 4-Star rating is often only 3 to 4 percentage points.

My team, the Medicare clinical program management team, worked very closely with many areas to create the formularies. We also worked closely with Prime’s Health Outcomes team to document the effectiveness of the formulary and validate the results. The rigor of the methodology they use instills confidence in everyone who works with them.

We showed clients the results of the program – a difference in difference study which was then compared to a control group. I’m proud that the products we offer are designed with data.

Prime wouldn’t have it any other way.


  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:®ion=stream&module=stream_unit&version=latest&contentPlacement=1&pgtype=sectionfront&_r=1
  2. “Multiple Chronic Conditions in the United States,” by Christine Buttorff, Teague, Ruder, and Melissa Bauman. Rand Corporation. Santa Monica, California. © 2017 RAND Corporation. Accessed at
  3. 8 reasons patients don’t take their medications,” in PRACTICE MANAGEMENT. OCT 16, 2015. Copyright 1995 – 2018 American Medical Association. All rights reserved. Accessed at:
Can Lowering Generics Member Cost Share Impact CMS Star Adherence Metrics? (Spring 2018)

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