Radar on Specialty Pharmacy

Optum, Inc. recently unveiled Optum Specialty Fusion, a specialty drug management solution that’s focused on streamlining care for people on those products and lowering medication costs. According to the company, which is part of UnitedHealth Group, the approach has the potential to deliver 17% total cost savings in health plans’ medical and pharmacy spend.

Providers are able to request prior authorization for specialty agents via a portal, which then compares treatment options, including their costs, across both the medical and the pharmacy benefit. According to the company, “informed by Optum data and insights, Specialty Fusion provides savings options such as preferred products, dosage management policies, best sites of care and additional cost-control levers such as available discounts and pharmacy networks.” The solution narrows down treatment options to the ones or one that “makes the most clinical and financial sense” and provides approval for that treatment in real time, regardless of the benefit the agent falls under. Optum maintains that this approach lessens “administrative hassle and results in an expected 50% faster access to therapy for patients, while lowering costs.” Specialty Fusion is available for large health plans.

When the COVID-19 pandemic struck, to say the health care system was disrupted is an understatement. Many people undergoing treatment for cancer rightfully were concerned about their potential exposure to the virus and were hesitant to leave their homes for care. In order to continue treating some patients, Horizon Blue Cross Blue Shield of New Jersey partnered with Rutgers Cancer Institute of New Jersey (CINJ) and RWJBarnabas Health to start a pilot to offer home infusion of cancer treatments and telemedicine support for eligible people, the first such program in the state.

In addition to not putting people at risk of acquiring an illness, home infusion means that people don’t have to travel for treatment. It also provides them with one-on-one care, close monitoring during infusions and the ability to schedule treatments around their personal schedule. These benefits are especially important for people with compromised immune systems.

The FDA has approved a handful of drugs to treat atopic dermatitis recently. Among them is LEO Pharma Inc.’s Adbry (tralokinumab-ldrm), an interleukin-13 (IL-13) antagonist. According to a Zitter Insights survey, payers may take a bit of a restrictive approach in managing the drug. And with multiple new biologics approved for the condition and more potential agents coming onto the market, payers may impose more utilization management strategies on the therapeutic class as a whole, say industry experts. 

On Dec. 28, the FDA approved Adbry for the treatment of people at least 18 years old with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those treatments are not advisable. The decision made it the first biologic that LEO Pharma has launched in the U.S. Recommended dosing is an initial dose of 600 mg via four 150 mg subcutaneous injections and then 300 mg every other week.

Social determinants of health (SDOH), which researchers have suggested account for up to 80% of health outcomes, can also complicate medication adherence, which can be particularly challenging for people taking specialty drugs. Specialty pharmacies are uniquely suited to address these issues and provide the support and resources that their patients need to overcome barriers to effective treatment, industry experts tell AIS Health, a division of MMIT.

According to the Healthy People 2030 initiative from HHS’s Office of Disease Prevention and Health Promotion, SDOH “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These factors can be grouped into five areas: