Nathan Downhour of Prime Calls for Clearer, More Sustainable Pharmacy Benefit Models | PBMI Innovator

Nathan Downhour, Pharm.D., vice president of strategic pharmacy solutions at Prime Therapeutics, is one of the inaugural winners of the PBMI Innovator Award, presented by Managed Healthcare Executive. The award recognizes leaders who are developing new solutions to meet the evolving challenges in the pharmacy benefit market.

In a recent conversation, Downhour shared his views on how the industry can become more transparent and sustainable—particularly for patients and retail pharmacies.

According to Downhour, a shift is already underway across the industry. Increased pressure from regulators, legislators, and consumers is pushing pharmacy benefit managers (PBMs) to adopt more transparent pricing models.

“We’re starting to see the introduction of cost-plus type models, where there’s an admin fee for an appropriate amount of work that’s added on top of the cost of a product, versus spread pricing,” he explained. “We’re seeing that across the board.”

But real change will require more than just pricing reform. Downhour emphasized the need to ensure patient access—especially in rural areas—and to rethink how retail pharmacies are supported.

“Retail pharmacies are under a lot of pressure right now,” he said. “We want to make sure patients have access to the drugs that they need. So how do we create a new model for retail pharmacies that’s durable and sustainable?”

He also pointed to the broader value that PBMs bring to the healthcare system, including clinical and administrative support that drives savings for health plans and employers.

“The industry, holistically, is certainly moving towards a more transparent model,” Downhour said. “There’s an appropriate fee that needs to be charged for the services we provide, and we provide tremendous clinical services, administrative services, and savings. We need to build a new model that really changes the fee structure—makes it more clear and easier to understand and digest.”