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11/3/2022 | Expert Insight

How PBM’s should support 5-Star Rated health plans

 Author: Mike Eaton, PharmD – Pharmacy Government Programs Director

The Centers for Medicare and Medicaid Services (CMS) have announced that Select Health Medicare HMO plans earned a 5 out of 5-Star Overall Rating for 2023 and its Medicare Advantage plan is among the highest-ranked in the country.  Select Health Medicare has received this prestigious rating for two years in a row. This rating places Select Health in the 99th percentile of health plans across the country and Select Health Medicare’s 5-Star rating includes 5-Stars for drug plan quality.

For over 25 years, Scripius has functioned as the Pharmacy Benefits Manager (PBM) for Select Health, which has over 1 million members and is the largest purchaser of prescription drugs in the state of Utah. Because of this unique relationship, Scripius is an expert in interacting with all health plan departments and can create unique PBM solutions to help solve complex issues that health plans face in Medicare, Medicaid, and Commercial lines of business. 

Here are some of the ways our drug management helped Select Health Medicare achieve an overall 5-Star rating. If you need 5-Star strategies for your plan, connect with us. We can help.

Raising the bar for Comprehensive Medication Review

Select Health Medicare was struggling with a 1-Star Rating for their Medication Therapy Management (MTM) program completion rate for the “Comprehensive Medication Review (CMR)” measure, having dropped from a 2-Star Rating the year before. Scripius implemented an enhanced MTM outreach and CMR process, which used our advanced analytics to identify 1) members who were mostly likely to respond to outreach, 2) what communication channels and timings produced the best member response, and 3) whether a multi-channel communication strategy would produce better results. Our analysis resulted in a system of optimally timed outreaches to selected members every three days during the 60-day period. Additionally, strategically timed “Unable to Reach” notices sent through preferred channels allowed more members to be contacted and scheduled for CMR. The result? Select Health improved from a 1-Star Rating to a 4-Star Rating in one year and has successfully maintained a 5-star CMR Rating for several years.

Boosting the Rating of Drug Plan measure

Select Health Medicare began with a 2-Star Rating for the “Rating of Drug Plan” measure. To help, Scripius first created and collected a “Mock CAHPS” assessment in order to understand member pain points, which were identified as coverage gap prices, and members feeling overwhelmed by the amount of phone calls they were receiving. Scripius addressed these concerns by developing “Entering Coverage Gap” communications, for members who are projected to enter the coverage gap during the next month. Communications inform members of their current status and help them calculate how much they will pay in the coverage gap for each of their medications. Scripius additionally developed specialized communications about the pharmacists who were making outbound calls to members. These communications helped members feel more comfortable with who they were talking to. Finally, Scripius created a weekly and automated process of thanking members, acknowledging those who Scripius connected with the previous week. These efforts helped Select Health Medicare improve from a 2-Star to a 5-Star Rating for the Drug plan measure.

Providing superior service for members with translation and TTY needs

Starting with a 4-Star Rating for the “Call Center-Foreign Language Interpreter and TTY Availability” measure, Select Health Medicare looked to Scripius to help achieve improvement. Scripius created functionality to route calls to an internal Select Health Medicare sales team, who are specially trained to receive calls and answer questions per the measure standards. Additionally, Scripius developed a system to track current performance and identify potential calls to challenge. As a result, Select Health Medicare went from a 4-Star to a 5-Star Rating in this measure in one year.

Improving outcomes for patients with high cholesterol

Select Health Medicare started with a 3-Star Rating for the “Part D Medicare Adherence for Cholesterol” measure. To help, Scripius initiated targeted outreach to pharmacies and prescribers, who were identified as being key allies in increasing adherence. For members, Scripius developed a system of daily outbound calls to those who were three days past their regular fill date, reminding them to fill their medication. Our team also takes the extra step of calling the pharmacy to get the prescription filled and ready for pick-up, if the member allows. If members continue to be unresponsive, outreach is maintained, and the pharmacy and prescriber are contacted to provide multiple channels of communication encouraging adherence. Scripius also helped develop a series of communications and outreaches encouraging these members to use mail order and available 100-day programs in order to encourage long-term fills. Finally, Scripius advised Select Health Medicare to upgrade benefits to include all statins on the lowest available formulary tier with opportunities for early refills. These efforts helped Select Health Medicare improve from a 3-Star Rating to a 4-Star Rating in one year in the cholesterol adherence measure.

Boosting Statin Use

As with Cholesterol Adherence, Select Health Medicare started with a 3-Star “Statin Use in Persons with Diabetes (SUPD)” measure. Scripius used automated predictive analytics along with social determinants to identify “denominator positive” members and initiated strategic communications to prescribers of those members, who had not had a statin fill. Scripius was able to educate prescribers about the importance of prescribing a statin with the patient’s diabetes medication(s) in these situations. Additionally, Scripius developed a system of quarterly communications to qualifying members to educate them on the importance of taking a statin. Towards the end of the Select Health Medicare plan year, the Scripius analytics team developed a targeted list of members who had filled a statin the previous year, but not in the current year. Scripius pharmacists then specially contacted those members to educate them about the importance of continuing statin medication. Finally, the Scripius and Select Health Medicare data teams were able to share data about member exclusion, allowing outreach to prescribers about coding appropriately to exclude specific members from the measure altogether. As a result, Select Health Medicare improved from a 3-Star Rating to a 4-Star Rating for the measure in one year.

What a change to Scripius can mean for you

Because of Scripius’ special and long-standing relationship with Select Health Medicare, we have seen it all, solved it all, and are expertly positioned to serve health plans and other payers in a way our competitors can’t. We will work hard for your health plan and your company will continue to innovate specific solutions for our clients. Let us show you how Scripius can interface with payers to create better outcomes, improve member satisfaction, and deliver 5-Star results. For more information check out or email