What do we do about members who: 

• Have a specific diagnosis for high cholesterol, but aren’t taking any medication for it?  
• Are receiving prescriptions for opioids from several different doctors? 
• Have a diagnosis for dementia but also have a prescription for one or more anticholinergic medications? 

Prime might give them a call. Or send a letter. Or click a text. Whatever the particular program and member preference, Prime is on it.  

Prime’s GuidedHealth Medication Management product uses integrated pharmacy and medical claims data to identify DTOs that have the most impact on cost, safety and health outcomes.  

“It engages doctors and members to act and make informed choices. It focuses on adherence and medication gaps in care for members with qualified diagnoses.”  

Improper and unnecessary use of medicines is also targeted, providing insights to areas where drug safety may be of concern. In 2022, GuidedHealth’s clinical rules engine identified 15.3 million total DTOs across all lines of business and completed 7.8 million prescriber and member interventions. 

“GuidedHealth’s care team model provides a higher touch, personalized outreach when needed. It supports Prime’s vision of viewing members more holistically through their health care journey – across pharmacy, behavioral health and medical needs.” 

Aligning care teams with clients allows Prime to create relationships – with the plan, their member population and their prescriber network – to support client-specific goals. Under this model, targeted outreach can be delivered to members deemed most important to a health plan. Simultaneously this creates opportunities for a more personalized engagement experience for members and their prescribers. 

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Case studies demonstrate care team impact 

Prime’s care team addresses these types of drug therapy opportunities:

Adherence and member savings 

Prime’s care team called a member to discuss medication adherence. The member said they were filling their medications for 30 days at a time due to cost. On further review, it was found the member was filling at a non-preferred pharmacy. The care team pharmacist identified a preferred pharmacy in the member’s area and discussed the cost savings associated with a change. Follow up showed the member: 

• Filling 90-day supplies consistently,  
• Adherence to medications,  
• A significant decrease in cost.  

Alternative therapy and member savings 

During a medication therapy management call, Prime’s care team pharmacist discussed the multiple inhalers a member was using to treat chronic obstructive pulmonary disease (COPD). In a review of the member’s formulary, a covered triple therapy inhaler was available. Changing to this inhaler would greatly simplify the member’s regimen and decrease overall costs. The member agreed, and the pharmacist pursued the change with the member’s prescriber. Follow up confirms the member has: 

• The medication needed to treat their condition,  
• A decrease in the number of inhalers, and  
• Cost savings associated with the change. 

Education and breaking down barriers to adherence 

During an adherence call related to statin therapy, a member indicated their cholesterol was stable and they were having side effects from the statin. As the call continued, the member became more comfortable. They member admitted they had picked up the prescription but had never started taking it due to concern about potential side effects. Prime’s care team pharmacist: 

• Found history of a previous stroke, 
• Addressed the member’s concerns, and 
• Provided education on the benefits of statin therapy. 

With this information, the member agreed that statin therapy would be worthwhile to try. The pharmacist took further action, calling the pharmacy for a refill. Follow up shows the member has continued to fill and maintain adherence.