Health Benefits 101: The Importance of Clinical Programs

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Clinical programs are a vital component of any comprehensive health benefits strategy. For employers and other plan sponsors seeking integrated pharmacy and medical benefits solutions, these programs promote safer medication use, help control or reduce pharmacy spending, and deliver compassionate member care. The combined effect is better overall cost and health outcomes, which is why understanding what clinical programs are, how they work, and why they’re such an imperative, results-driven piece of the health benefits puzzle is crucial.

Below, we’ll explore ins and outs of clinical programs and how they enable employers and health plans to provide better care for plan members.

What Are Clinical Programs?

At their core, clinical programs are services layered on top of standard pharmacy benefit management (PBM) functions. In this way, they can be considered enhancements that help with the "M" in PBM - management of the plan. These programs generally support plan sponsors in five critical areas:

Utilization Management

Cost Containment

Patient Safety

Population Health

High-Touch, Personalized Care

Each category is designed to address different challenges and opportunities within a covered population.

The Five Pillars of Clinical Programs

Utilization Management: Promoting Safe, Appropriate Use [of Medication]

Utilization management programs are a first line of defense against waste and inappropriate prescribing. By applying tools like prior authorization (PA), step therapy, and quantity limits, plan sponsors can ensure appropriate medication use that is both clinical and cost conscious, reducing unnecessary spend and minimizing risk.

Cost Containment: Maximizing Value

Innovative cost containment strategies help reduce pharmacy spend without sacrificing care quality. Our Rx Smart Save program, for example, empowers members to switch to equally effective, lower-cost alternatives through both digital notifications and direct pharmacist outreach. The program operates at two levels:

Level 1: Members are prompted via app or web portal about potential savings on medication alternatives.

Level 2: Clinical teams proactively connect with members, prescribers, and pharmacies to facilitate a seamless transition.

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Patient Safety: Proactive Risk Mitigation

Patient safety programs help identify dangerous drug interactions, duplicate therapies, and risky prescribing patterns.

For example:

Capital Rx’s clinical team presented a poster at the Pharmacy Quality Alliance 2024 Annual Meeting showing that duplicate therapy pharmacy point-of-sale messaging can be an effective tool to reduce the inappropriate, concomitant use of two popular diabetes medications, the GLP-1 agonist and DPP-4 inhibitor.
Pharmacist-led programs such as Rx Retro focus on medication deprescribing to enhance patient safety, reduce adverse drug events, and improve healthcare outcomes.

Judi’s ability to identify drug therapy concerns in real-time, even across multiple prescribers and pharmacies, helps drive patient safety solutions such as opioid safety initiatives, pharmacy point-of-sale edits, and adherence reminders — all of which contribute to member well-being and drive better quality outcomes.

Population Health: Driving Better Outcomes at Scale

Population health strategies target common chronic conditions such as diabetes, hypertension, and obesity. Clinical teams leverage prescription and medical claims data to identify at-risk individuals and intervene to close gaps in care before small issues turn into costly complications. Clinical programs within this category can help plan sponsors lower total cost of care through data-driven solutions to improve Medicare Star ratings or tailor interventions that address trends in utilization or risk. Member outreach can include medication adherence reminders or a comprehensive medication review (CMR) by a pharmacist, helping members stay on therapy and avoid serious events.

“As part of Capital Rx's Medication Therapy Management (MTM) program, outreach was conducted to a New York-based Medicare member for an annual Comprehensive Medication Review. During this personalized consultation, an MTM-trained Capital Rx pharmacist reviewed the member's prescriptions and over-the-counter medications to identify potential drug interactions and adverse effects. Although the member reported no history of medication side effects and was taking his medications as prescribed, he indicated that he was taking two medications from the same class for the treatment of the same condition. The Capital Rx pharmacist successfully deprescribed one of the two medications, which not only helped prevent potential adverse outcomes but also resulted in cost savings for both the member and the client.”

Personalized Care: A Human Touch

Healthcare is human. Capital Rx offers a variety of innovative, tech-enabled clinical programs that are human-led and help to address the unique needs of each member. This can be in the form of pharmacogenomics (tailoring medications to genetics), diabetes and weight management, or even personalized musculoskeletal care (virtual physical therapy for muscle, joint, pelvic, and movement health).

Positive outcomes from personalized care look like:

An Rx Activate Member in a Commercial Employer Group

A Capital Rx member with depression, anxiety, obesity, and high cholesterol joined Rx Activate’s Obesity Step Solution, OSS. They started OSS already taking a GLP-1 for weight loss but reported significant side effects to the Vida Care Team during enrollment. The member’s registered dietitian worked to personalize an intensive medical nutrition therapy and care plan to help achieve the member’s health goals. Within 5 months, the member achieved 17% weight loss* and reported reduced symptoms of mild depression and anxiety.

An Rx Reverse Member Testimonial

"I am down several pounds, and I am just getting started. My eyes are opening to the possibilities of a healthier lifestyle. I’m so thankful that I didn’t have to become a fully blown diabetic to take advantage of this amazing program. Today was the first day I noticed that a t-shirt that used to be tight on me is loose. I like to envision that my organs are getting healthier, and my body size will continue to get slimmer. It’s empowering. I’m thankful that I can check my blood sugar and ketones and feel confident that I’m on track to change the trajectory of my life.”

Technology & Data Integration: The Modern Advantage

Technology is also a key component in this conversation. Our team leverages our proprietary enterprise health platform, Judi®, across a plethora of use cases. Modern technology like Judi enables our clinical teams to:

Identify members eligible for cost savings or at risk for medication misuse

Streamline communication among members, prescribers, and pharmacies

Process real-time test claims of drug alternatives for an optimal member experience

Enable robust reporting

Automate clinical interventions

Crucially, our unified pharmacy and medical claims platform, Judi Health™ (the first of its kind) allows plan sponsors to gain a more holistic view of a member’s health journey and, ultimately, deliver total cost of care reduction as well as a better plan experience.

For example, while pharmacy claims data might flag someone as adherent to their diabetes medications, pairing this with medical claims data could also reveal gaps in care and frequent ER visits, signaling additional opportunities to outreach.

Measuring Impact: What Success Looks Like

A clinical program’s value can be represented in a few different ways:

Clinical Outcomes: Increased medication adherence, safer prescribing, fewer adverse events, and improved biometrics resulting from chronic condition management.

Financial Results: Fewer duplicate therapies, appropriate use of generic alternatives, avoidance of high-cost interventions (like surgeries or hospital stays), and overall plan savings from total cost of care reduction.

Member Experience: Education, access, and simplified navigation of benefit complexities.

Choosing & Implementing Clinical Programs

With a wide range of clinical interventions available, how can plan sponsors decide what’s right?

Focus on these core questions:

Where are your highest costs? Use claims data to identify waste or inefficiencies.

Which chronic conditions are most prevalent and costly? Population-specific programs yield the greatest return.

What do adherence rates reveal? Poor adherence often signals both clinical risk and future expense.

Best Practices for Implementation:

Leverage data analytics to guide program selection.

Prioritize member experience—streamlined communication and support make all the difference.

Engage prescribers and members through targeted interventions and education.

Set clear KPIs for outcomes and financial value.

Ensure technology is up to the task—cloud-based platforms are table stakes for agility and insight.

Looking Ahead: Clinical Programs Become Strategic Assets

As pharmacy and health benefits programs evolve, clinical programs will continue to play a pivotal role in cost management and how patient-centered care is delivered. Leading the way is the integration of pharmacy and medical data, along with predictive analytics to personalize interventions and keep healthcare human.

Forward-thinking plan sponsors recognize that robust clinical programs aren’t just a “nice to have.” On the contrary, they are essential tools that can help reduce the total cost of care while also helping members achieve improved health outcomes.

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Ready to see how clinical programs can optimize your pharmacy benefit? Contact us to learn more about our PBM and health benefits partnership models that put clinical quality and total cost management front and center.

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*Results may vary. Research indicates the typical overweight or obese participant will experience a bodyweight reduction of 7.2% and 7.5%, respectively.

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