Radar on Specialty Pharmacy

While a variety of strategies are available to manage specialty drugs in the pharmacy benefit, that’s not traditionally been the case with drugs that fall under the medical benefit. Prime Therapeutics LLC is adding to its offerings for medical benefit management with MedSelect, its newly launched national medical drug management list.

Prime has populated MedSelect with therapies based on their clinical efficacy and/or superiority and cost- effectiveness. It combines utilization management and site-of-care strategies to produce savings and appropriate drug use. The company says it expects the list will help Blues plans achieve a 4% to 7% reduction in medical drug costs.

As the specialty pharmacy industry continues to grow, more entities within the health care system are boosting their capabilities in this area, and various health systems are implementing some form of a specialty pharmacy. These entities have some issues and challenges that may differ from those of traditional specialty pharmacies. In order to make sure their voices are heard, a group of seven health systems plus a specialty pharmacy integrator have joined together to form a new alliance known as the Health System Owned Specialty Pharmacy Alliance (HOSP).

In an Aug. 18 blog on his Drug Channels website, Adam Fein, Ph.D., CEO of Drug Channels Institute, a subsidiary of Pembroke Consulting, Inc., shared information from the American Society of Hospital Pharmacists’ survey of 487 pharmacy practices located in hospitals. That survey found that 26% of respondent hospitals in 2019 owned a specialty pharmacy, up from 20% in 2018 and less than 9% in 2015.

With the FDA’s approval last month of Onureg (azacitidine), people with acute myeloid leukemia (AML) now have an oral version of a longtime injectable treatment within that class. Zitter Insights found that more than half of oncologists polled are likely to prescribe the drug as a maintenance treatment for the condition.

On Sept. 1, the FDA approved Bristol-Myers Squibb Co. unit Celgene Corp.’s Onureg, a tablet, for the continued treatment of adults with AML who achieved first complete remission or CR with incomplete blood count recovery following intensive induction chemotherapy and who are not able to complete intensive curative therapy (RSP 9/20, p. 8).

Years of advances in driving down cancer occurrences and deaths could be completely reversed by the COVID-19 pandemic. A recently published study shows screenings, diagnoses and treatment for various cancers dropped dramatically from March through July when compared with 2019 rates.

Researchers analyzed 6,227,474 claims from a provider clearinghouse representing 5% to 7% of the Medicare fee-for-service population. In April, at the height of the pandemic, screening for breast cancer was down by 85%; screening for colon cancer dropped by 75%; prostate cancer screening declined by 74%; and lung cancer screening was down by 56%. Hospital outpatient Evaluation and Management visits dropped 74% in April; new patient E&M visits fell 70%, and existing patient E&M visits declined 60%.

The United States is seeing a surge of innovative specialty therapeutics coming onto the market, many of which offer potential treatments for conditions that previously didn’t have one. But many of these newer therapies are launching with expensive price tags, driving up spending on health care services. A Prime Therapeutics LLC study found a huge increase in people who have annual drug spend of at least $250,000 — so-called “drug super spenders”— from 2016 to 2019.

Researchers analyzed pharmacy and medical benefit claims from a commercially insured population of 17.9 million members between January 2016 and December 2019. They defined “cost” as plan and member cost share after network discounts but did not include manufacturer rebates or coupons. For drug super spenders, researchers used diagnosis codes to determine a clinical condition category based on their drug use.