Managing medical-benefit drug spend is critical — and we can help

Between an increase in use and prices, specialty drug spend is one of health care’s highest ranking concerns. Today, nearly 60 percent of specialty drug costs are paid under the medical benefit.[1]

There may be additional opportunities to manage specialty spend under the medical benefit that aren’t in place today, due to:

  • Lack of transparency of drug costs
  • Lack of care coordination
  • UM requirements that differ by site of care
  • Variable doctor reimbursement arrangements
  • Inability to see the total cost picture

At Prime, we can help you manage specialty drug spend, no matter what the care setting or under which benefit it’s paid. As part of connected specialty drug management, we offer a full suite of solutions designed specifically to help you manage drug spend paid under the medical benefit. Watch this short video to learn more about our medical spend management capabilities.

Products in our Medical Spend Solutions suite include:

Medical drug review
We use a comprehensive review process to encourage use of clinically appropriate medicine while reducing unnecessary spending:

  1. First, we review members’ clinical data to confirm that their prescribed treatment plans align with best practices.
  2. Then, we apply proven UM techniques.
  3. Prime’s medical policy criteria takes into account preferred product strategy and dose management.

Our thorough criteria and drug management can result in improved outcomes, safety and savings.

Oncology management

Cancer medicines account for more than half of medical-benefit drug spend.[2] And the category continues to grow. Currently, there are 800 oncology drugs in clinical trials.[2]

Because they’re often billed under the medical benefit, managing this spend can be complex. But managing oncology drugs can significantly reduce costs, and Prime can help. In addition to traditional UM, we offer integrated care management programs, split fill and clinical decision support platforms.

These efforts have been paying off. Prime Therapeutics Specialty PharmacyTM members adhere to oral oncology treatment at a rate 3.8 points higher than members using retail pharmacies.[3]

Rebate management
We leverage our relationships with manufacturers to negotiate maximum rebates and drive down net costs. Plus, we handle all the administration so you don’t have to.

[1] Prime Therapeutics. (June 17, 2014). Spotlight on specialty.

[2] AIS Specialty Pharmacy News. (2010).

[3] Prime Therapeutics. (2013). Commercial data for 11 Blue Cross and Blue Shield Plans.




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