Prime can help make clinical programs easier and more effective

For the millions of Americans living with chronic disease, getting access to the right medicine at the right time is essential. But clinical programs designed to manage utilization can backfire. If there’s a delay at the doctor’s office or pharmacy, the member may not follow through with treatment. That can lead to adverse health events and increase total health care costs.

Prime can help. We offer several products and opportunities that align with our connected model:

Doctors can electronically send prescriptions directly to a pharmacy from the point of care. This reduces administrative time and eliminates medical errors from handwritten notes.

Electronic prior authorization (ePA)
Doctors and pharmacists can conveniently submit utilization management (UM) requests online and get real-time notifications of Prime’s prior authorization (PA) decision. ePA is available for all drugs and nearly all prescription drug programs. It makes life easier for doctors by reducing paperwork and reducing callbacks. More importantly, it helps members get the medicine they need faster by reducing ePA turnaround time up to 90 percent.[1] To learn more, watch our ePA video.

Medical drug review
We conduct a UM review of specialty drugs covered and paid for under the medical benefit. This helps manage all drug spend, regardless of where care is given. To learn more, see our story on managing medical spend.

UM programs:

  • Prior authorization: Requires members to meet certain criteria before drugs are covered. It both improves safety and reduces costs.
  • Step therapy: Optimizes selection of appropriate drugs to treat specific conditions. This encourages doctors and members to think about generic and lower-cost drugs, not just higher-cost, brand-name drugs.
  • Quantity limits: Restricts the quantity of a drug a member can fill at one time for a specific prescription. The benefits are threefold: Quantity limits improve safety, minimize waste and reduce costs.

Where do you see the greatest opportunities to promote doctors' use of e-prescribing or ePAs in your market? Call your Prime representative.

[1] Prime internal clinical review utilization numbers, 2013.


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