UPMC Health Plan


Bill Ries
UPMC Health Plan


UPMC for You and PA Pharmacists Care Network Launch New "Whole Person" Pilot to Pay Pharmacists for Expanded Services

Value-based plan focuses on enabling pharmacists to provide certain clinical services for Medicaid members with asthma and COPD

Pittsburgh (March 8, 2021) – UPMC for You and Pennsylvania Pharmacists Care Network (PPCN) today announced details of a pilot program designed to reimburse community pharmacists for delivering certain clinical services to individuals with one of two major respiratory conditions, asthma, and COPD (chronic obstructive pulmonary disease).

"Paying pharmacies for clinical services is another example of UPMC Health Plan's commitment to leading the way in implementing value-based reimbursement models to deliver enhanced care for our members," said Chronis Manolis, RPh, Chief Pharmacy Officer at UPMC Health Plan. “Our members trust their community pharmacists, so it makes sense to develop a value-based approach that puts them front-and-center helping individuals manage asthma and COPD.”

This new payment model will be augmented with a "whole person" approach to care, including comprehensive care planning and increased coordination of care for UPMC for You members with respiratory diseases.

PPCN is a network of more than 140 pharmacies who are committed to providing high quality, patient-centered care across the state. These pharmacists receive specialized training to achieve proficiency in providing direct patient care in a variety of health conditions. UPMC for You members who fill respiratory medication(s) for asthma and/or COPD at one of these participating network pharmacies will receive clinical program support by a pharmacist who will work to improve the care of patients through enhanced clinical engagement. This innovative initiative will place more focus on increasing the quality of patient care by providing clinical services reimbursement outside of the traditional pharmacy dispensing reimbursement model, which focuses primarily on drug dispensing payments.

In the U.S., there are 16 million adults who have a diagnosis of COPD and more than 25 million Americans with a diagnosis of asthma. Many members have clinical gaps that need to be addressed to prevent disease progression and achieve better clinical outcomes. In this pilot, pharmacists will enhance care when a member is filling medication(s) by having in-depth, face-to-face discussions surrounding inhaler technique, medication adherence and other clinically identified issues or barriers related to the chronic health condition(s). According to the Centers for Disease Control (CDC), the treatment of COPD alone was estimated to cost $49 billion in 2020. By improving outcomes and keeping individuals healthier, this pilot program can also help reduce costs associated with additional—and potentially avoidable—health care interventions.

Throughout this program, the pharmacists will be able to assist with care coordination by developing care plans to optimize medication regimens with the member's physician, synchronize medication fills to a common date to aid with adherence, assess the impact of environmental triggers inside and outside of the home, and collaborate with UPMC for You pharmacy and nurse case management teams through disease state management program referrals.

"Among the most trusted and accessible health care practitioners, community pharmacists play an important role in caring for the medication-related needs of their patients, especially those with chronic health conditions like asthma and COPD. We are thrilled for the opportunity to evaluate this impact in partnership with UPMC for You," said Stephanie McGrath, PharmD, Executive Director of Network Operations, PPCN.


About UPMC Insurance Services

Serving 4 million members, UPMC Insurance Services is owned and operated by UPMC, a world-renowned health care provider and insurer based in Pittsburgh. UPMC Insurance Services includes commercial products from UPMC Health Plan for groups as well as individuals. Commercial products also include workers' compensation and employee assistance from nationally known Workpartners. Government products include Medicare Advantage (UPMC for Life); special needs plans for those eligible for Medicare and Medical Assistance (UPMC for Life Complete Care and UPMC Community HealthChoices); Medical Assistance (UPMC for You); and Children's Health Insurance Program (UPMC for Kids). Also part of UPMC Insurance Services is Community Care Behavioral Health, one of the nation's largest managed care behavioral health organizations. For more information, visit upmchealthplan.com.