Prime Program Connects Patients with Financial Solutions for Specialty Drugs

Prime Therapeutics has launched a new specialty pharmacy care solution. Called Advocate+, the program provides members support for navigating utilization management requirements and finding financial assistance. The program will be available beginning Jan. 1, 2025, for members of health plans and their employer group clients and national account employer groups.

Nathan Downhour, Pharm.D.

“The process of obtaining specialty medications is more complex than the typical retail experience, and these medications generally come with higher costs compared to standard retail drugs,” Nathan Downhour, Pharm.D., senior vice president, Pharmacy and Care Solutions, at Prime, told Formulary Watch. “We understand that receiving a diagnosis such as cancer or MS can be daunting, and we want to ensure that patients have the support and resources needed during this challenging time."

He said patients envision the process of obtaining medication to be a straightforward path: a doctor makes a diagnosis, writes a prescription, and the patient receives the medication from the pharmacy after insurance benefits are confirmed. “However, for those requiring specialty drugs — often patients who are seriously ill or have recently received a challenging diagnosis — the journey is rarely this simple. The process for specialty medications is often more complex and less predictable than the typical retail drug experience.”

Affordability of prescription drugs is a key issue for Americans, according to a survey done last year by KFF. This is especially true for those who are taking four or more prescriptions; 37% of these respondents say they have difficulty affording their prescriptions, compared with 18% who currently take three or fewer prescription medications. Those with household incomes of less than the $40,000 are more likely to report difficulty affording medications.

Additionally, 31% adults in the KFF report not taking their medicines as prescribed at some point in the past year because of the cost. This includes 21% who report they have not filled a prescription or took an over-the counter drug instead, and 12% who say they have cut pills in half or skipped a dose because of the cost.

Advocate+ identifies financial assistance options for a member – such as manufacturer copay cards/coupons, foundations, and social determinants of health (SDOH) assistance programs – using key prerequisite information such as insurance type and diagnosis to match with relevant opportunities.

Related: Prime Therapeutics Launches Pharmacy Solution for Specialty Drugs

Advocate+ builds on a program Prime/Magellan Rx launched this summer called Pharmacy Match, which includes an expanded specialty pharmacy network and allows for real-time comparison of drug costs across the network.

Downhour said in an interview at the time that Pharmacy Match was a first step to create a system for specialty care that is intelligently designed, technology-enabled and that improves the experience for members, while eliminating complexities and driving savings.

Advocate+ leverages TailorMed’s technology solution to assess patients' eligibility and enrollment. Its platform uses a data-driven process to flag financially at-risk members and identify relevant funding opportunities based on their insurance, clinical and demographic data. The platform draws on a database of more 7,000 assistance programs, addressing medication needs across diagnoses.

Although there is a cost to clients for Advocate+, Downhour said, the expense will be offset by the savings achieved through enhanced management and support for specialty drugs. “Clients benefit from Advocate+’s improved member experience and aligned incentives through reduced waste and appropriate utilization,” he said. “As a part of the Advocate+ suite, Pharmacy Match lowers drug costs for clients by driving competition through an expanded specialty pharmacy network.”

Members will be able to access the program through several channels, including digital, SMS, self-service options and traditional phone calls.