The average PBM can’t take on rising specialty costs like we do. It’s a whole new level of expertise.
These drug management tools aren’t new. But application in the specialty space takes precision. For specialty pharmacy, Prime and your Blue Cross and Blue Shield Plan manage across the medical and pharmacy benefit so that drug costs are actually managed, not just moved.
1. Utilization management (UM) can improve safety and lower costs
UM programs help members consistently use the drugs that provide the best outcomes. Programs like prior authorization (PA), step therapy and quantity limits can guide members to the most clinically appropriate and cost-effective medicines at the right time.
Medical drug review addresses the use of specialty drugs that are covered and paid for under the medical benefit. It works in much the same way as UM programs on the pharmacy benefit.
Prime provides an efficient and effective process for drugs managed under the medical benefit. It includes a dynamic decision tree and experienced nursing staff.
2. Preferred drugs can drive savings
Benefit design can guide members to preferred drugs and crafting the right member cost share supports adherence. This strategy includes negotiating aggressive rebates and using formulary exclusions — without losing sight of helping members get the medicine they need to improve their health.
3. Care management breaks down adherence barriers
These programs guide members to correctly use their medicines and manage side effects. That helps them stay on treatment — and helps lower costs.
- Care management includes optimizing member care, therapy and integration
- Member care: adherence risk assessments, condition-specific nursing assessments
- Therapy: generic substitution, therapeutic interchange and preferred product programs
- Integration: referrals, faster interventions and integrated data
4. Channel management helps manage costs
Directing drug delivery channels helps improve adherence while managing costs. Using Prime Specialty Pharmacy exclusively for dispensing specialty drugs can save employers money.
For specialty drugs, channel management also includes site of care. We find the most effective place for the member with a specific condition on a specific drug to receive an infused medicine.
Employers need support to commit to more of these programs. Prime and Blue Cross make a great team to:
- Show you the right tools
- Help you pick the tools that apply to your market
- Walk with you through implementation
- Evaluate the results
- Set expectations in a challenging environment
Help your clients step up for this. Give your health plan representative a call.
Prime Therapeutics Specialty Pharmacy™ is a wholly owned subsidiary of Prime Therapeutics LLC.