Pharmacy pay-for-quality pilot helps manage chronic conditions

More than 84 percent of U.S. health care costs go toward treating chronic conditions.[1]

How can we make sure these dollars are working as hard as they can? A new pilot called pharmacy pay-for-quality offers one approach. It rewards results. It drives greater efficiencies, better outcomes and healthier members.

What does “pharmacy pay-for-quality mean?” We don’t reimburse pharmacies the same across the board. Our reimbursements are based, in part, on clinical outcomes. Here's how it works. We:

  • Actively identify members who should be on certain medicines based on medical diagnoses.
  • Reach out to those members and/or their doctors to point out the possible gaps in care.
  • Provide information pharmacists can use to reach out to members and help them better follow their treatment regimen.

What pharmacists say can make a big impact on member adherence. That’s why this pilot focuses on relationships between community pharmacists and members.

Late in 2014, Blue Cross and Blue Shield of North Carolina and Prime started a pilot for a new pharmacy pay-for-quality program within its commercial population.

This six-month pilot centers on optimizing care and improving adherence to medicines for chronic conditions. It focuses on members who take medicines to treat diabetes, high blood pressure and high cholesterol. The pilot encourages better results by partially tying pharmacy reimbursement to clinical outcomes.  

Consumers rank pharmacists as the second most trusted profession.[2] What they say can make a big impact on member adherence. That’s why this pilot focuses on relationships between community pharmacists and members. Connecting them encourages a longer-term relationship based on trust, potentially leading to better outcomes.

High-risk, high-priority members are identified through targeted intervention programs. The pilot encourages pharmacists to reach out to the doctor or member. The goals are to:

  • Identify safety concerns related to members with high blood pressure and diabetes not taking an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB); reach out to these members or their doctors with a goal of adding an ACE/ARB
  • Achieve 80 percent or greater member adherence to the prescribed therapy

Do you want to try something new for your members?
Pilots are how we find out what works and what doesn’t work for you and your members. Some pilots give us new insight into cost, quality and improved outcomes. Some pilots might reinforce the status quo.

Do you have an idea for a pilot that could bring value to your members? Prime was built on a foundation of collaboration. And we’ve recently implemented a more rigorous, disciplined pilot process to evaluate new ideas and concepts. If you have an idea for improving outcomes, increasing efficiency or lowering costs — we want to help bring it to life. 

Contact your Prime representative to learn more about the pharmacy pay-for-quality pilot or to discuss ideas for other future pilots or innovation.


[1]“Chronic Care: Making the Case for Ongoing Care.” Published by the Robert Woods Johnson Foundation. Prepared by Gerard Anderson, Ph.D., Director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health.  Accessed at:

[2]Newport, F. (2012, December). Congress retains low honesty rating. Retrieve from



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