CarelonRx: Collaboration between payers, specialty pharmacies can help people lead healthier lives

We all know someone affected by a complex illness. Cancer. Crohn's disease. Multiple sclerosis.

Each of these illnesses need active clinical management, medication education and logistical support for administering and optimizing medications. That's where collaboration within healthcare is needed to help patients lead healthier lives.

Payers and specialty pharmacies have the privilege to come together to help change lives for the better.

Collaboration between specialty pharmacies and payers is crucial to improving health outcomes for patients with complex illnesses. So where do payers and specialty pharmacies converge and what can each bring to the table to offer support?

Focus on patients

Payers and specialty pharmacies can start by taking a consumer-centered healthcare approach. This places people at the center and allows for the connection and sharing of information to support patients and members wherever they may be in their healthcare journey. It's the idea of promoting whole health and connected health, rather than a disjointed system.

When payers and specialty pharmacies work together, or align, they are able to combine their technology and clinical experience to create a holistic view of a patient's medical and pharmacy needs. This allows for visibility into a patient’s pharmacy claims, their complete medication list, health outcomes, and barriers to care. The integration of this information enables providers, pharmacies and payers to make coordinated care decisions that help prevent adverse medication interactions, increase medication adherence, and ultimately improve quality of care.

According to a study out of the University of Pittsburgh (Pa.) titled, "Dropping the Baton: Specialty Referrals in the United States," 25% of people said their results and records from one provider did not reach another provider in time for their appointment, which is just one example that underscores the gaps in connectivity, timeliness and communication within our current healthcare system.


Collaboration is crucial because many patients have several doctors, and more than 40% use more than one pharmacy. In addition, the FDA receives over 100,000 reports associated with medication errors every year.

Both payers and specialty pharmacies each have unique skillsets, resources and leading experts, that when combined, would help reduce these gaps and better patient outcomes.

Harness expertise

Payers are able to drive cost management and offer adherence/compliance assistance and specialty therapy guidance. Payers' teams of pharmacists and pharmacy technicians are available 24/7 to answer members' questions, and provide customized outreach to assist with medication management and adherence.

Specialty pharmacies provide additional access to skilled pharmacists and pharmacy technicians, as well as physician consultations to improve management of adherence and adverse effects. Specialty pharmacies also dispense 99.98% of prescriptions with zero errors, and distribute 99.91% of prescriptions with no errors, according to URAC.

By combining their unique capabilities, payers and specialty pharmacies are estimated to save $545 billion between 2020 and 2029.

Through collaboration, payers and specialty pharmacies can partner to deliver need-based support, provide clinical interventions, monitor therapies of each patient, expedite time to therapy, produce real-time reporting on the patient journey and increase medication adherence for those who rely on them most.

Paul Marchetti is president of CarelonRx and Mark Montgomery is CEO and president of BioPlus Specialty Pharmacy, which are Elevance Health companies.

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