Integration means collaboration

By carving pharmacy coverage into medical coverage, we can care for our members holistically.

Seamless integration of medical and pharmacy data enables Capital Blue Cross to take a holistic approach to controlling overall health care spend, as prescription drug costs are considered in the overall management of a member’s condition. We refer many members with high dollar pharmacy claims. Not having pharmacy data limits our ability to identify potential case management candidates for case management evaluation. Choosing a carve-out model may contain prescription drug costs, but the choice runs the risk of increasing medical costs. An actuarial analysis by a team at Premera Blue Cross showed a 7.5% higher medical claims cost for carved-out business, even while there was a 15% drop in pharmacy costs. Overall costs were still 2.2% higher with carved-out pharmacy.

That integration allows us to maintain a member-focused mindset, especially when it comes to pharmacy benefits.

We have a unique 360° view of member data so we can close gaps in care, find cost-effective and safe alternative medications or treatments, and enroll employees in programs to help them best manage health conditions. When medical and prescription coverage are combined through Capital Blue Cross and Prime, member information and data is aligned to drive informed decisions. An award winning study published as a peer-reviewed article in the Journal of Managed Care and Specialty Pharmacy, a journal of the Academy of Managed Cared Pharmacy (AMCP) shows that employers who integrate their medical and prescription drug coverage experience overall lower hospitalization rate, 7% lower rate of emergency department visits, and $148 less in medical costs per member per year on average.

Integration works

Members in carve-in group experienced


Overall lower hospitalizations rate


Overall lower rate emergency depart visits


Less in medical costs PMPY1 on average

Administrative efficiency

Integrating medical and prescription drug benefits provides a single point of contact for medical and prescription services, enhancing the value of efficiency and service, and providing:

  • Better coordination of the customer experience and issue resolution
  • A focused team approach, including clinical and analytic expertise
  • Insights and recommendations to help improve plan performance
  • More efficient data integration to meet health care reform requirements on combined accumulators

Members, specifically, have:

  • A single point of contact for 24/7 customer service
  • Enhanced clinical resources to help manage medical conditions
  • One-on-one medication consultation for members with complex needs
  • Access to a pharmacy network of both retail and local pharmacies

Members benefit from coordinated care between pharmacy, disease/case management staff, and other Capital Blue Cross teams.

Having real-time pharmacy data aligned with health claims data, our case managers can tailor their approach to assisting individuals. And, with insight into pharmacy history, Capital Blue Cross has the greatest opportunity to identify risk for specific conditions, allowing for early intervention and engagement. Pharmacy data may be the earliest trigger of a diagnosis, such as when a claim for oral diabetes medication precedes a medical claim with a diabetes diagnosis. Without pharmacy data, our ability to impact health is delayed, such as when a member is non-compliant with asthma medication, but medical claims do not signal the need for intervention.

Timely use of information can reduce adverse drug interactions, prompts earlier referrals for coordinated care of complex cases, and avoids gaps in care.

A pharmacy specialty team identifies members for medication counseling and education, further helping to ensure appropriate drug therapy and adherence.

Want to know what pharmacy coverage could look like for your clients?

Contact your Capital Blue Cross sales representative.