Products & Services

Integrating Data and Managing Spend

At Prime, we help employers maximize cost savings while ensuring appropriate drug therapy. We work with our clients to look at pharmacy benefits and costs in the context of the total health care spend. This allows us to develop programs that ensure that pharmacy costs are carefully managed and not merely shifted to the medical benefit.

And, while our clinical programs are available to all clients, a variety of our programs may be integrated with the Blues' medical plans, which offer added value by combining pharmacy and medical claims data to help manage overall health care costs and promote quality care.

Prime's Clinical Programs

• Adherence Program
• Drug Alerts—Generic and Safety
• Drug Utilization Management
• Drug Utilization Review

Adherence Program

Adherence programs measure whether individuals are taking key medications that help maintain a certain level of health. By taking these medications as prescribed, poor outcomes — like emergency room visits and hospital stays — can be prevented. Our adherence report charts how well members within a specific client or employer group population are adhering to their medication plan.

Proactive measures (such as reducing financial barriers through generic utilization or the use of mail-service pharmacies) reinforce and increase adherence by making medication refills less expensive and more convenient.

Our integrated adherence program uses both medical and pharmacy claims data. Predictive modeling logic and medical claims data helps further identify members with the potential for a future adverse medical event. With this information, plan sponsors can drive utilization of medications with proven positive health outcomes. This efficiency is measured through an assessment of category spend and targeted utilization.

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Drug Alerts—Generic and Safety

Drug alerts provide both members and physicians current, relevant, drug-specific health care information, benefitting both employers and members.

Our Generic Drug Alerts identify members taking a particular brand-name drug that will soon be launched as a generic. These members receive a targeted communication that promotes the generic drug, with the potential to increase generic utilization, decrease cost barriers, improve overall health and reduce the overall pharmacy spend.

Prime's Safety Drug Alerts provide targeted outreach that communicates safety information to physicians with patients who are affected by a particular safety concern. Our vast claims data provides physicians a relevant member list that results in a clear call-to-action.
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Drug Utilization Management

Our Utilization Management programs are designed to ensure members receive the safest, most cost-effective drug. We provide guidance to both physicians and members that help them make the best prescription drug choices based on improved health, lower out-of-pocket costs and built-in safety protections.

An external panel of physicians and pharmacists regularly reviews our programs for clinical effectiveness and helps ensure that quality health care is never sacrificed for cost.

Utilization Management programs include:

• Step Therapy drives safety and cost savings by encouraging members to try a first-line agent, usually a generic alternative, before coverage is provided for a second-line, usually more costly, brand-name drug.
• Prior Authorizations provide an additional review of a prescription against Food and Drug Administration product labeling and clinical guidelines before a particular drug is covered under a member's benefit plan. We require prior authorization for those medications that have proven potential for misuse, overuse or inappropriate use, which may raise both clinical and economic concerns.
• Quantity Limits promote safe and effective drug use and reduce waste by tracking a predetermined limit by quantity per prescription or duration.

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Drug Utilization Review

Drug Utilization Review is a key component to helping health plans and employers gain control of rising drug costs. Concurrent Drug Utilization Review (at the point of sale) and Retrospective Drug Utilization Review (through analysis of pharmacy claims history) helps identify opportunities to improve the quality and reduce the cost of pharmacy care for plan sponsors and members.
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