Pharmacy Integration: New Models

To best advance whole health and influence outcomes, patient experience, and cost of care, we must consider pharmacy levers. Recent studies have found that, in the United States, drug costs account for approximately 15% of overall healthcare spending.1 Total drug spending in the U.S. stood at $577 billion in 2021, up 7.7% from 2020.2 Further, over 48% of people in the U.S. have used at least one prescription drug in the past 30 days.3 The inclusion of pharmacy as a component of whole health is, therefore, critical.

To address these dynamics, we should look at pharmacy differently — not as a transactional process of filling prescriptions but as part of a whole-health experience. What is needed are strategies, plans, benefits, and tools designed to support the whole person, in partnership with their care teams. That means creating a new model of pharmacy that meets consumers where they are in their healthcare journey to help achieve quality outcomes and drive affordability.

A comprehensive, connected set of pharmacy benefit management services includes:

  • Working with care providers to improve medication adherence and screen for potentially dangerous drug interactions, supported by advanced analytics.
  • Working with pharmacies — independent ones and national organizations — to dispense drugs to patients in a timely and accurate manner.
  • Dispensing medications, educating patients and their families about treatment options, and innovating to improve convenient access to prescription drugs.
  • Providing critical support for people with complex conditions, including care management support from a dedicated specialty pharmacy nurse.
  • Negotiating with drug manufacturers to secure competitive drug prices on behalf of our clients. This drives healthcare cost savings, which are passed back to payers and employers to help lower premiums.

Working Together With Care Providers for Positive Outcomes

CarelonRx collaborates with physicians to deliver faster decisions, improved outcomes, and lower total costs. Our approach empowers care providers with actionable insights across medical and pharmacy benefits through:

Patient-specific, integrated medical and pharmacy information within practice-management workflow systems.

Real-time benefit checks that display drug list status, medication alternatives, and prior authorizations within the care provider workflow.

Our digital platform, which provides cost and quality opportunities for physicians and alerts them to medication adherence gaps.

Practically speaking, we send gap-in-care messaging via electronic medical record (EMR) connectivity through partnerships with Epic and other EMR providers. By embedding real-time benefit checks into the EMR, the information is available at the care provider's fingertips at the point of prescribing. By having dedicated pharmacists working directly with those care provider practices, we help care providers identify consumer opportunities and put action plans in place. Finally, we provide actionable reports to care providers in value-based arrangements, clearly identifying consumers with care-gap opportunities.

By looking at the total picture of a consumer's health across pharmacy and medical, we develop targeted strategies to improve whole health, while managing costs. Our pharmacists partner with physicians in the field to create and maintain best practices in areas such as the prescribing of medications and gap closures. Clinicians are incentivized to look at the full picture of care delivery rather than just pharmacy costs.

To help clinicians provide optimal care to their patients, we apply the latest clinical insights and best practices, while also providing robust support to consumers to ensure they can more easily follow treatment as prescribed.

Encouraging Adherence

Medication adherence is a key factor in a patient's successful course of treatment. While adherence rates of 80% or more are needed for optimal therapeutic efficiency, it's estimated that most patients only take their medications for chronic conditions about half of the time. Nonadherence can affect quality and length of life, health outcomes, and overall healthcare costs. In fact, $100 to $300 billion in healthcare costs could be curtailed annually by addressing medication adherence.5

CarelonRx takes a whole-health approach, using data across pharmacy and medical benefits to develop strategies to support consumers in taking their medications as prescribed. Notably, having integrated benefits that include CarelonRx has been shown to improve drug compliance, thus improving healthcare outcomes and lowering costs:

  • In one recent four-year study, nonadherent consumers with integrated coverage exhibited substantial improvement in medication adherence in multiple therapeutic classes, including diabetes, hypertension, hyperlipidemia, asthma, and depression.6
  • In another case-controlled study of more than 51,000 continuously enrolled consumers with specialty conditions, those who had integrated medical and pharmacy benefits demonstrated significantly better outcomes and lower costs than their counterparts.7
    • Consumers with integrated benefits experienced 9.4% lower inpatient utilization and $169 in per member, per month all-cause medical savings and superior medical care gap closures across multiple chronic conditions.7
  • Among consumers using specialty medications, those with integrated benefits experienced lower overall medical cost related to behavioral health conditions, including depression ($3,132 per member, per year lower than those without integrated benefits) and anxiety ($1,896 lower).7

At CarelonRx, the proof of the value of integrated benefits is in the numbers. In 2021, we saw:7


Drug cost trend across medical and pharmacy benefits overall


Drug trend excluding specialty drugs


Clients with a negative drug trend overall and a negative specialty drug cost


Decrease in drug costs over a 12-month period by working directly with clinicians to identify high-cost, low-value drugs and place alerts within the electronic medical record system

Costs of prescription medications can be an issue for many patients. CarelonRx drives savings on drug costs while ensuring continued access to care for consumers. In 2021, our services led to a low, single-digit trend in savings on specialty and nonspecialty drugs. Out-of-pocket expenses were reduced, providing greater value for consumers and clients in high-performing pharmacy networks. Additionally, new clinical programs resulted in an estimated $750 million in incremental savings.7

Convenient access to medications can also be a barrier to adherence. Together, we have an opportunity to build more convenient, consumer-centered approaches to drug dispensing. For example, our CarelonRx Pharmacy will deliver medications directly to a patient's doorstep, paired with a consumer-friendly app that provides clear updates on prescription status and connection to support via live chat with clinical staff.

Forward Together

The right pharmacy partner is an important contributor to whole health and can help care providers address gaps in patient care, create effective treatment plans, and manage the overall patient experience. CarelonRx's solutions leverage advanced analytics and technology to create new models of pharmacy care that deliver results and connect the dots for consumers.

1 IQVIA. Drug Expenditure Dynamics 1995-2020: Understanding medicine spending in context (October 14, 2021): iqvia.com. 2 Tichy, E.M. PharmD, MBA, BCPS, FCCP, Hoffman, J.M. PharmD, MS, Suda, K.J. PharmD, MS, et al, National trends in prescription drug expenditures and projections for 2022, American Journal of Health-System Pharmacy, Volume 79, Issue 14, 15 July 2022, Pages 1158-1172, https://doi.org/10.1093/ajhp/zxac102. 3 Centers for Disease Control and Prevention, National Center for Health Statistics, FastStats: Therapeutic Drug Use — Data from 2015-2018 (September 6, 2022): cdc.gov. 4 CarelonRx internal human resources data. Includes only clinical professionals working in clinical roles. October 2022. 5 Medication Adherence: The Elephant in the Room, US Pharm. 2018;43(1)30-34. 6 CarelonRx research (2022). 7 CarelonRx 2021 Drug Trend Report.