Nathan Downhour, Pharm.D. | PBMI Innovator

Nathan Downhour, Pharm.D.

Simplifying healthcare for members and providers is the right thing to do, even if it’s not profitable, says Nathan Downhour, Pharm.D. At Prime Therapeutics, where he is senior vice president of strategic pharmacy solutions, Downhour is working to enhance the member experience and improve patient health outcomes.

Making medication more affordable and accessible are top priorities for Downhour and Prime as they work to shape the delivery model for prescription drugs, especially for those with complex conditions. The ultimate goal is to bring together different service providers and partners to create a model that drives value and improves the patient experience.

“It’s in our purpose statement, where we say that we want to provide the kind of care you’d want for your loved ones,” Downhour says.

Managed Healthcare Executive and the Pharmacy Benefit Management Institute (PBMI) have selected Downhour for recognition in the inaugural PBMI Innovators Award program, which recognizes industry professionals who are leading innovation in pharmacy benefits.

Prime, headquartered in the suburban Twin Cities of Minnesota, is a not-for-profit pharmacy benefit manager (PBM) co-owned by 19 Blue Cross Blue Shield plans. It serves 27 million members in Blues plans across the United States. Although it is among the six largest PBMs in the country in an industry that some critics say has gotten too consolidated, Prime’s structure and culture allow it to focus on the health of its members and corporate responsibility, the company says.

“Our key focus is simplifying healthcare for members, providers and clients,” Downhour says. “All the while we do what’s right, not necessarily what’s most profitable. That looks like broadening our pharmacy networks to match members with the best-fit pharmacy suited to their unique needs instead of mandating that patients fill prescriptions exclusively at owned pharmacies.”

He says Prime aims to improve patient health outcomes through evidence-based and coordinated care while at the same time driving affordability for plans and employers. Prime is known in PBM and managed care circles for publishing high-quality research on health outcomes, adherence and cost of care. Its posters are often medal winners at the Academy of Managed Care Pharmacy meeting. Recent research by Prime has flagged the problem of “persistence” — patients sticking with a prescription over a long time — among those with GLP-1 prescriptions for weight loss.

Downhour, 49, was born and raised in Arizona, where he lives with his wife and three sons, including 19-year-old twins. He and his family enjoy traveling, including to Europe, and going to their son’s soccer games. Downhour received his doctor of pharmacy degree from the University of Arizona in Tucson.

Downhour joined Prime in September 2021 and leads the development, implementation and coordination of Prime pharmacy distribution and supply chain strategies. Previously, Downhour served as senior vice president of specialty pharmacy for Optum Rx and executive vice president of strategic programs at Avella Specialty Pharmacy. (Avella had been acquired by Optum Rx Specialty in 2018.)

“I spent my first 18 years with an independent specialty pharmacy. As such, we were often at odds with PBMs as we sought access to payer networks and improved reimbursement rates,” he says. At Optum Rx, Downhour says he realized the patient’s experience needed “a major uplift. The pivotal moment for me was realizing that I had a better opportunity to have a greater impact on patients by working to solve these challenges from within the PBM space and working for an organization like Prime than from the outside.”

At Prime, Downhour has been instrumental in developing the Advocate+ program, a pilot for specialty medications launched this year. Prime is pairing Advocate+ with the Pharmacy Match program, which was launched in 2024 and includes a network of pharmacies that compete on price for volume for specialty drugs. This allows for real-time comparison of drug costs across the network, helping to drive affordability for patients and clients, he says.

Pharmacy Match was developed to work alongside utilization management programs and complement other programs such as IntegratedRx, a Prime solution for more complex conditions.

“We are seeing increased demand for specialty and high-cost drugs due to growth in new drug therapies, indications and personalization,” Downhour says. “Specialty medications already make up more than 50% of overall prescription drug expenditures. We recognize patient barriers in specialty medicine that can hinder adherence, including cost concerns, logistical issues and social drivers of health.”

Through Advocate+, patients fill their prescriptions at a pharmacy supported by a team of care specialists, Downhour says. Once a prescription is ordered, those specialists connect with patients to guide them, answer questions and help them navigate insurance issues, such as prior authorization.

“The pilot is meeting our expectations,” Downhour says. “We have some great anecdotes from patients who were struggling to get their medications.”

In one case, Prime’s care managers were able to help a patient navigate secondary insurance to transfer a prescription to a network pharmacy, and the patient was able to get the medication the next day with no out-of-pocket costs.

Part of the program, Downhour said, is ensuring that patients are getting the right kind of copay assistance and have the lowest out-of-pocket costs.

“The patients have someone they can rely on to help shepherd them through that program and be their advocate along the way,” Downhour says.

An important piece of this new model would be expanding pharmacy networks to ensure better patient access.

“We need to ensure durable accessibility for our patients,” Downhour says. “I think retail pharmacies are under a lot of pressure right now on how they can create a sustainable model, especially in our rural environments. We want to make sure patients have access to the drugs that they need.”

Downhour says Advocate+ benefits pharmacies as well, which are getting an appropriate reimbursement for the product that is dispensed. So far, Advocate+ is seeing 2% to 4% savings.