Study Finds Generic Drug Discount Programs Requiring Membership May Result in Incomplete PBM and Health Plan Data Membership drug discount programs appear to be having a minimal but statistically significant impact on claims capture rates

SAN FRANCISCO, April 19, 2012 /PRNewswire/ -- Generic drug discount programs that require membership and provide the medication through an unadjudicated cash transaction may result in incomplete pharmacy benefit manager (PBM) and health plan data, according to a new study by Prime Therapeutics (Prime), a leading PBM. Such programs may result in a small but significant effect on PBM reporting and clinical programs such as tracking patient drug adherence and managing patient therapy. The study will be presented tomorrow at the Academy of Managed Care Pharmacy (AMCP)'s 24th Annual Meeting & Expo in San Francisco.

A steady increase in generic drug discount programs has occurred over the past few years, including well-known $4 generics programs, but little research has been conducted to measure the impact of these programs on pharmacy claims data. Transactions within these programs can potentially be processed as cash, eliminating the need to submit for PBM adjudication, the process through which clinical rules, pricing, eligibility, etc. are applied before the prescription is provided, resulting in PBMs' inability to manage adherence and medication therapy management programs. In the case of generic drug discount programs requiring membership, such as Walgreens and CVS, transactions are not processed through the member's insurance, potentially resulting in unadjudicated claims.

"Unadjudicated claims for generic drugs that result in incomplete PBM data can in turn negatively influence the adherence and medication therapy management programs we have in place to better serve our members and improve patient outcomes," said Patrick Gleason, PharmD, director of clinical outcomes assessment at Prime. "Generic discount programs are no doubt on the rise and it has become increasingly important to determine how these programs affect our members."

The study used the drug levothyroxine as a means to measure the impact of generic drug discount programs because physicians prescribe it as a standard treatment for hypothyroidism and nearly all strengths of the generic drug are included in generic drug discount programs.

To identify changes in levothyroxine utilizers prescription claims capture rate, researchers from Prime reviewed claims data from Blue Cross Blue Shield plans with Prime pharmacy benefit coverage in the Midwest and South. Members utilizing generic levothyroxine for at least 120 days during January 1, 2006 to June 30, 2006 were placed into one of three pharmacy groups (Walmart/Sam's Club, Walgreens/CVS or all other pharmacies) based on drug discount implementation date and membership requirement.

Of the 3.5 million commercially insured members, 25,895 per 1 million members had a levothyroxine claim with supply on July 1, 2006. Of the 13,758 members continuously enrolled for five years and meeting all analysis criteria, 6.4 percent utilized Walmart/Sam's Club (which does not require a special membership), 25 percent utilized Walgreens or CVS (which do require membership) and 68.6 percent utilized all other pharmacies. At the end of the four-year post period, researchers found that levothyroxine claims capture persistency was 87.6 percent for Walmart/Sam's Club, 77.7 percent for Walgreens or CVS and 84.6 percent for all other pharmacies, p<0.001. Loss of levothyroxine claims capture persistency was defined as a 180-day supply gap.

"This study provides the first objective evidence that generic drug discount programs requiring membership have a minimal but significant affect on claims capture rates, while it appears that non-membership programs continue to do their part in submitting drug discount program claims," Gleason said. "Although further research is needed to better understand the relationship between claims capture rate and other generic drugs, these study findings provide key initial insights that illustrate the potential consequences of generic drug discount programs on PBMs and their members." 

Prime Therapeutics is a pharmacy benefit management company dedicated to providing innovative, clinically-based, cost-effective pharmacy solutions for clients and members. Providing pharmacy benefit services nationwide to nearly 20 million covered lives, its client base includes Blue Cross and Blue Shield Plans, employer and union groups, and third-party administrators. Headquartered in St. Paul, Minn., Prime Therapeutics is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those Plans. Learn more at

SOURCE Prime Therapeutics


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