Managed care pharmacist program sees 9:1 return on investment

EAGAN, Minn. – A program by pharmacy benefit manager (PBM) Prime Therapeutics LLC (Prime), in which a managed care pharmacist reviewed members’ drug therapies including a number of high-cost specialty medications, saved a net $2.4 million in health care costs in one year. A recent study showed this savings equates to a 9:1 return on the program investment.

For the program, one managed care pharmacist selectively reviewed integrated medical and pharmacy claims and prior authorization data of 1.5 million commercially-insured members to identify potential savings opportunities. Approximately 1,500 members were reviewed, and of those 365 members were further identified as having a savings opportunity.

Savings were realized from the pharmacist conducting outreach within the health plan, and with providers, pharmacies and members depending on the most appropriate method to optimize the success of the intervention. This outreach helped promote appropriate use of medicines, identify suspicious utilization and evaluate various cost savings opportunities.

“Increasingly, pharmacists are an integral part of the health care team,” said Patrick Gleason, PharmD, assistant vice president, health outcomes for Prime. “Our goal is to help members improve their health while also saving money. This program demonstrated the importance of providing managed care pharmacists with appropriate access to data that helps ensure the right treatment is administered via proper processes and at manageable costs.”

A similar health plan study of managed care pharmacists released in March 2017 also saw financial success with a 10:1 return on investment. The study analyzed drug therapy programs where managed care pharmacists used medical and pharmacy claims data to recommend drug therapy optimization with members and providers utilizing specialty and HIV drugs.

“Managed care pharmacist models have been shown to pay for themselves. And while they continue to evolve, they can improve even further with access to additional information,” added Gleason. “Data such as laboratory results, genetic testing, electronic health records and predictive modeling capabilities could focus efforts further to help target tailored therapeutic interventions.”

This gold award-winning research will be presented at the Academy of Managed Care Pharmacy (AMCP) 2020 virtual learning event April 20-24.