Scaling a People-First Pharmacy Model

Contributing experts: Amy Mulderry and Lisa Morris, RPh

Pharmacy is the most common touchpoint in the healthcare system, with about 50% of people having taken at least one prescription drug in the past 30 days. That figure illustrates the significant impact pharmacy benefits can have on overall health, as well as care providers’ ability to effectively and efficiently manage it.

Our pharmacy benefit manager, CarelonRx, strives to make the pharmacy experience simpler for prescribers and members. Leveraging integrated service offerings, we’ve made progress on improving medication adherence and health outcomes, while driving affordability and focusing on person-centered care.

Growing the Impact

In 2024, CarelonRx made several key investments across the pharmacy care continuum to support care providers and the people they serve. Expanding our footprint allows us to help people manage their health more holistically and affordably with simpler benefits and tools.

Our health plans' value-based care arrangements integrate medical and pharmacy metrics to help optimize prescribing. They've driven a $98 per-member-per-month savings in overall medical spending.¹

In addition, we acquired BioPlus Specialty Pharmacy in 2023 to help address specialty cost issues, scale offerings, and improve the consumer and care provider experiences.

Our recent growth is as strategic as it is clinically important: Managing touchpoints across the dispensing continuum better positions us to give people faster, easier access to the medication they need, when and where they need it. At the same time, it supports medication adherence and facilitates a whole-health experience.

Driving Affordability

As a pharmacy benefit manager, our tools, products, and services come together with medical benefits to offer holistic, integrated care, while driving affordability. Deep expertise and a comprehensive data ecosystem help identify the appropriate medications and condition management approaches for each patient. They also drive costs savings and, in collaboration with care providers, ensure the right medications are used at the right time.²

CarelonRx’s clinical pharmacists work with health plan clients to offer approaches for pharmacy benefit design, formulary management, and medication management programs. These elements combine to improve price transparency and support holistic care, leading to cost savings and quality improvements. Additionally, our clinical pharmacy team works side-by side with care providers in value-based contracts to help improve the care and health outcomes of people whose prescription medication we manage.

By collaborating with value-based care providers, CarelonRx helps drive cost savings and quality

improvements across patient populations. As a result:^{3, 4}

One Ohio care provider reduced high-cost, low-value prescriptions to yield a $373,000 reduction in costs.

One Indiana care provider increased extended-day prescriptions by 42%.

One Georgia care provider improved formulary compliance to generate a savings of $178,000.

Reducing Administrative Burden

CarelonRx also works to reduce administrative burden for care providers, most recently with the help of large language learning models. These models use data to find lab values and diagnoses to auto-approve prior authorization, which makes for less paperwork for care providers.

It’s all part of our aim to make pharmacy simpler and better connected for the care providers we partner with and the people we serve.