A potential $1.5 million pharmacy bill prompts collaborative investigation

The call came from one of Prime’s clients. A pharmacy director noticed something strange on a report. One of their members — we’ll call her Sarah* — had specialty pharmacy claims adding up to approximately $129,000 within just one month. That meant those costs could have added up to around $1.5 million a year. Something wasn’t right.

The pharmacy director called Prime to tell us about what was going on. Sarah wasn’t using Prime’s specialty pharmacy, but she still needed our help.

Both Prime and the Blue Plan looked into the situation and discovered that Sarah’s pharmacy claims were adding up so quickly because of an automatic refill from her pharmacy. The medicine the pharmacy kept sending was not something that should have been taken on a daily basis, but rather during a crisis.

The pharmacy director called Sarah’s prescribing doctor and told him about the situation. The doctor was very concerned and talked to Sarah about how this certain medicine should have been taken. He even suggested another medicine she could use less often that might help her manage her condition better.

Because of the concern for Sarah, Prime will continue working with its client to monitor her care and support and to eventually transition her to Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy). If Sarah had been getting her medicine from Prime Specialty Pharmacy in the first place, she would have been assigned a nurse from Prime to help her manage her condition. That nurse would have called her every month to help with delivery coordination or to help her manage any side effects. The nurse would also give her advice about taking the right kind, and dose, of medicine at the right time.

Prime has an entire care coordination team with pharmacists, nurses, care coordinators and insurance specialists on staff. The Prime team works with the member and those involved in their care to coordinate needed support and medicine delivery. In this case, instead of Prime’s client calling Sarah’s doctor, Prime Specialty Pharmacy would have called her doctor to talk about Sarah’s medicine, making sure all those involved in her therapy were on the same page.

End-to-end support helps members take medicine correctly and can eliminate gaps in care. This support helps members save money and live healthfully.

Sarah’s story highlights the unique connection Prime has with its clients. This particular client was not even using Prime’s specialty services, but still felt like he could reach out for help. And of course, we said “yes, we want to help you and your member.” We worked together to help Sarah get the right care and medicine she needed. 

                                                                                                

*Prime changed the name of this member for confidentiality reasons

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Chief Clinical Officer


David has oversight of Prime’s clinical services. He leads formulary, utilization management and clinical program development and builds strategies for total health management integration with health plan partners.