Can your pharmacy benefit improve quality – and cost – of care?

A Massachusetts man is now taking a vital medication, thanks to a call from his health plan.

The man suffered a heart attack last summer. Within a month of being sent home from the hospital, he had run out of his blood thinner medication.

Because his employer chose a Blue Cross Blue Shield of Massachusetts plan that integrates medical and pharmacy benefits, the man was able to benefit from a special resource: pharmacists at the not-for-profit health plan who review member cases and reach out to help those who may not be taking their medication as directed, or who may be having trouble affording their prescription, as well as cases where the pharmacy cost is unusually high.

When Blue Cross pharmacist Josephine Loya called the man to ask if he had any questions about his medicines or discharge instructions, “he told me his blood thinner medication cost $100, making it difficult for him to afford,” recalled Loya recently.

The medication relaxes blood vessels and reduces the buildup of sodium and liquids in the bloodstream to help the heart pump blood more effectively.

“I was concerned,” said Loya. “Not taking his medications as prescribed could lead to serious complications like blood clots, another heart attack and hospitalization, and even worse.”

So she went to work on the member’s behalf.

Loya called the member’s cardiologist and got a refill of the blood thinner ordered. She also examined his health plan and helped guide him to an in-network pharmacy with no out-of-pocket costs for his blood thinner.

“He was very grateful,” she remembered, “and surprised that a pharmacist from his insurance company would call and help with this.”

Why the pharmacy benefit matters for employers and their workers

Three in ten Americans report not taking a medication as prescribed because of the cost, according to a 2023 KFF survey. That can lead to hospitalization or even a preventable death.

That’s why programs like Blue Cross’s are potential life-savers.

The pharmacy benefit, covering prescriptions, is the most utilized benefit in health insurance. Some employers choose to “carve out” the management of their pharmacy benefit to a third party, hoping to save money.

"Integrating the two benefits," as the employer of the heart attack patient did, "can help members have more coordinated care and a better experience," said Mary Beth Erwin, chief pharmacy officer for Blue Cross.

“By combining the medical and pharmacy benefit under one plan, we can offer our members and the clinicians who care for them a simplified but more aligned and transparent care experience, aiming for better health outcomes and lower costs,” Erwin said.

Making that difference is why Loya loves her job. “I think there’s definitely instant gratification for me having this role, stepping in and make this impact on a member. I don’t think many insurers go the extra mile to ensure the member has have everything they need.”