When it comes to managing chronic illness, taking the right medication at the right time can be the difference between stability and a medical crisis. For the more than 70 million Americans enrolled in Medicaid, many of whom live with multiple chronic conditions, barriers such as fragmented care, limited transportation, and inconsistent access to providers, make medication adherence especially difficult.
While these challenges are longstanding, they require renewed attention. States are actively seeking scalable, value-based strategies to improve outcomes for Medicaid beneficiaries. One increasingly effective solution is the collaboration between pharmacy benefit managers (PBMs) and community pharmacies, combining clinical data insights with local, personalized care delivery.
Medicaid members face distinct challenges
Compared to individuals with commercial insurance, Medicaid beneficiaries are more likely to be managing multiple chronic conditions, including diabetes, asthma, cardiovascular disease, and mental health disorders. And they often do so while navigating social drivers of health like housing instability, transportation, food insecurity, and inconsistent access to primary care.
These compounding barriers increase the risk of poor medication adherence, which in turn drives preventable emergency room visits and hospitalizations. Improving adherence in this population is not simply a pharmacy task, it is a care coordination imperative.
The power of PBM and pharmacy collaboration
Community pharmacists are among the most accessible healthcare professionals. Many patients interact with their pharmacist more often than with a physician, making pharmacists uniquely positioned to identify and address barriers to adherence such as side effects, regimen confusion, or missed refills, especially in rural areas. They are a key resource to improving care for Medicaid members.
But access alone is not enough. When PBMs and managed care organizations collaborate with local pharmacies, they create a structured system that supports consistent engagement, care continuity, and accountability.
Through enhanced models of medication therapy management, these partnerships allow pharmacists to do more: synchronize medications, prepare custom packaging, schedule deliveries, monitor adherence, and communicate directly with prescribers. PBMs play a critical role in enabling this by supplying the data infrastructure, clinical decision support, and analytics needed to identify members most at risk, and empower pharmacists to intervene.
A case study in coordinated impact
CarelonRx developed the Community Pharmacy Total Care Program (CPTCP) in 2021, to operationalize this PBM-pharmacy partnership. The program connects members of Elevance Health-affiliated Medicaid plans with high-performing independent pharmacies that offer services such as home delivery, medication synchronization, and personalized education.
Working with CPESN USA, the program now includes more than 500 pharmacies across 11 states. CarelonRx uses advanced analytics to identify members, often those with diabetes, respiratory or cardiovascular disease, or behavioral health needs, who would benefit from additional pharmacy support. Outreach is then coordinated between pharmacists and plan representatives, creating a seamless handoff and engagement process.
Recent evaluation by Elevance Health’s Public Policy Institute found that among nearly 500 Medicaid members engaged in CPTCP for at least 12 months, medication adherence improved by 6 to 11 percentage points, depending on the drug class. Compared to a matched cohort of nonparticipants, adherence gains reached up to 29 percentage points. Participants also improved across multiple HEDIS metrics, including a 20 percentage point increase in adherence to statin therapy for cardiovascular disease. Meanwhile, nonparticipants saw declines in many of the same measures.
These findings demonstrate that when PBMs and community pharmacies work together, they can deliver results that neither could fully achieve alone, closing critical care gaps while improving the patient experience.
Looking ahead
Pharmacy-centered care coordination models provide a pragmatic, scalable, and locally responsive pathway to better health outcomes. Their success depends on well-designed incentives, data interoperability, and alignment with each state’s Medicaid priorities.
As policymakers and health plans continue to look for high-impact, equity-minded strategies, it is time to recognize the role of PBM-pharmacy partnerships as a cornerstone of care transformation. In communities where traditional care delivery can fall short, pharmacists, supported by integrated PBM infrastructure, can serve as both trusted health advisors and vital connectors within the care ecosystem.
Stacey Decembrele, MPH, is Staff Vice President of Pharmacy Network Management, Strategy & Contracting at Elevance Health’s pharmacy benefit manager, CarelonRx; and Nirali Parikh RPh, BCGP, CDE, Pharmacy Account Director for CarelonRx’s Community Pharmacy Total Care Program.
