Breaking Through Barriers with Value-Based Plan Design

January 15, 2025

Finding a Valuable PBM Partner

Facing increased pharmacy benefit expenses, Blain’s Farm and Fleet, a Midwestern employer group, desired to improve plan performance. Specifically it was interested in educating eligible members about the benefits available to them, promoting cost-effective behaviors and identifying cost-savings opportunities via real-time modeling. Blain’s was also seeking enhanced support for its coronary heart disease (CHD) and diabetes case management program, which could benefit many of its members.

Developing a Focused Strategy

Collaborating with Blain’s to develop a focused strategy for targeted member populations, Navitus proposed the use of value-based plan design programs. Tailored to specific population needs, these programs encourage medical care and improve access to high-touch services by reducing or eliminating financial barriers. Evidence suggests that this promotes adherence, improves member health and can ultimately reduce hospitalization and medical costs.

With these goals in mind, Blain’s implemented CHD and diabetes condition management programs that reduced the copay for generic drugs from $10 to $2 and preferred brand drugs from $25 to $10 for enrolled members.

Increasing Member Adherence

As a result of the lower generic copay, Blain’s saw its generic utilization rate increase to over 9%.

More importantly, adherence rates for members enrolled in Navitus’ condition management program increased significantly, as shown in the table at the right.

Value-based programs are an effective solution for helping members remain adherent to their medications and better manage their disease states, ultimately lowering medical costs for both members and plans.

Getting Started

Are you interested in exploring a truly transparent, pass-through model could lower your plan spend and increase value to your employees? Contact us at [email protected] to learn more.

Stay Informed and Connected

Receive expert insights, healthcare tips, and important updates on pharmacy benefits, drug recalls, and more—straight to your inbox.

Examining Trends that Drive Informed Decisions

Now Available: 8th Annual Drug Trend Report

See the latest results and access industry insights you need to navigate current trend drivers.

Related blogs

Navigating Healthcare and Improving Outcomes

PBM 101: The Three PBM Business Models

PBM 101: The Three PBM Business Models

In the pharmaceutical and healthcare industry, pharmacy benefit managers (PBMs) are regarded by the media as intermediaries between drug manufacturers, pharmacies, health plans and plan sponsors. But they’re so much more than that. PBMs act as conduits…

An Automated Approach to Diagnosis Verification of GLP-1 RA for Type 2 Diabetes Mellitus (T2DM)

An Automated Approach to Diagnosis Verification of GLP-1 RA for Type 2 Diabetes Mellitus (T2DM)

This study examines the impact of implementing an automated point-of-sale diagnosis verification system for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) compared to traditional utilization management approaches….

Navitus to Remove Stelara® from Formulary July 1, 2025, Adds Biosimilars to Drive $120 Million in Savings 

Navitus to Remove Stelara® from Formulary July 1, 2025, Adds Biosimilars to Drive $120 Million in Savings 

As the nation’s first 100% transparent, pass-through PBM, we continue to advance medication affordability by prioritizing upfront, real-time savings over rebated models….

Achieving Outstanding Results with Tailored Network Strategies

Achieving Outstanding Results with Tailored Network Strategies

A medium-sized city in Michigan with 1,350 members was seeking ways to lower its pharmacy benefit costs, which were growing under its existing traditional pharmacy benefit manager (PBM). With its member covered by a two-tier, open formulary including…

Breaking Through Barriers with Value-Based Plan Design

Breaking Through Barriers with Value-Based Plan Design

Facing increased pharmacy benefit expenses, Blain’s Farm and Fleet, a Midwestern employer group, desired to improve plan performance. Specifically it was interested in educating eligible members about the benefits available to them, promoting cost-effective…

Finding a Solution to Lower Prescription Drug Costs

Finding a Solution to Lower Prescription Drug Costs

The Rural Arizona Group Health Trust (RAGHT) wanted to gain better control of its escalating drug trend with its large, traditional pharmacy benefit manager (PBM). Having only worked with traditional PBMs in the past, RAGHT was interested in exploring…

Empowered by Strategic Opportunities and Service Excellence

Empowered by Strategic Opportunities and Service Excellence

Putnam | Northern Westchester Health Benefits Consortium (PNW HBC) was the first municipal cooperative health plan in the state of New York to become certified by the Department of Insurance. They are dedicated to meeting — and exceeding — the standards…

QALYiQ Program Delivers Significant Savings for Both Members and Health Plans

QALYiQ Program Delivers Significant Savings for Both Members and Health Plans

As part of their treatment plan for hypophosphatasia (HPP), a rare genetic disorder affecting bone and teeth development, one of our members required Strensiq, a medication designed to manage HPP. However, Strensiq’s annual treatment costs ranged from…

RISE: Reporting and Intervention for Stars Excellence

RISE: Reporting and Intervention for Stars Excellence

RISE is a comprehensive Star Ratings Improvement program that focuses on positive outcomes for Medicare Part D (Part D) clinical measures, including: medication adherence for diabetes medications, medication adherence for hypertension, medication adherence…

previous arrow
next arrow