Health insurers to drug manufacturers — “no work, no pay”

Health insurers to drug manufacturers — “no work, no pay”

More and more drugs on the market come with high price tags – and questions about whether they are worth the cost. Sustainability of the health care system is being questioned. So the push is on by health insurers to make drug manufacturers prove the value of their drugs.

How CareCentered Contracting™ works

Prime created CareCentered Contracting more than four years ago. The program was designed to confirm a drug’s ability to reduce hospitalization and slow disease progression, when taken appropriately. In doing so, it aligns payers, members and providers by focusing on improved health. 

The first contracts Prime negotiated with drug manufacturers were for better pricing based on clinical outcomes. These contracts were typically drug/class specific. Today, CareCentered Contracting agreements can focus on a variety of aspects, including:

  • Channel: Directs drug use to mail or specialty pharmacies to support better adherence levels/ management
  • Education: Encourages drug adherence
  • Testing: Encourages lab testing to determine if drug is working
  • Health outcomes: Reimbursement to Prime and/or clients for a drug if it does not accomplish its intended purpose

Since the program began, contract areas have included diabetes, hepatitis C, autoimmune conditions (like rheumatoid arthritis or psoriatic arthritis) and osteoporosis.

Prime recently preferred two cholesterol-lowering medicines, Praluent® and Repatha®, on its national drug list. As part of the co-preferred arrangement, Prime negotiated CareCentered contracts with both drug makers.

Integration gives us the edge

When it comes to outcomes-based contracts, being closely connected to Blue Plans gives Prime a big advantage. Specifically, it gives Prime access to the pharmacy and medical data needed to truly evaluate health outcomes. More easily than PBM competitors, Prime can integrate the pharmacy and medical data that support these contracts.

Because of privacy issues, Prime does not provide member-specific information to manufacturers. Our focus is on contracts that provide value for aggregate percentage or number of claims meeting certain criteria.

Prime’s CareCentered Contracting is another innovative way our Blue and Prime connections make a difference. Members get the right medicine, which improves health outcomes, which reduces overall health care costs. 

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