Radar on Specialty Pharmacy

High cost is only one characteristic of specialty drugs that makes managing them so important. They fall under both the pharmacy and medical benefits, they have complicated treatment regimens, and they have fraud, waste and abuse (FWA) potential. Recent research from Prime Therapeutics LLC shows that a specialty drug managed care (SDMC) pharmacist working with a health plan resulted in substantial savings. The study also reveals the importance of having integrated pharmacy and medical benefit data, as well as prior authorization data.

SDMC Pharmacist Is Specialized Position

An SDMC pharmacist is a specialized position that “requires advanced clinical knowledge of drug therapies, as well as deep understanding of pharmacy and medical drug claim interpretation (e.g., dose, waste and frequency),” explains Patrick Gleason, Pharm.D., assistant vice president of health outcomes at Prime.

Prime Therapeutics LLC recently released the results of two studies focused on two classes of high-cost biologics, asthma and hereditary angioedema (HAE). Both conditions have seen new therapies recently and may be candidates for value-based contracts.

While more than 25 million people in the United States suffer from asthma, about 5% to 10% of those suffer from severe allergic or eosinophilic asthma. While asthma overall has a societal cost of around $56 billion, those patients account for almost 50% of that cost. Global Initiative for Asthma 2019 guidelines recommend an asthma biologic for this subset of patients, and the first Prime study examined the use of five biologics: Cinqair (reslizumab), Dupixent (dupilumab), Fasenra (benralizumab), Nucala (mepolizumab) and Xolair (omalizumab).

On April 15, the FDA approved the first drug for patients with low-grade upper tract urothelial cancer, UroGen Pharma Ltd.’s Jelmyto (mitomycin). It offers patients a nonsurgical option for a condition that often requires numerous surgeries (see brief, p. 8). While most commercial payers surveyed about its management said they will manage it per its FDA label, a handful said they are likely to manage it less restrictively.

The cancer is rare and develops in the lining of the upper urinary tract, ureters and kidneys. Because of the complexity of the anatomy of the urinary tract system, the condition can be challenging to treat. According to UroGen, “The current standard of care includes multiple surgeries and most patients require a radical nephroureterectomy, which includes the removal of the renal pelvis, kidney, ureter and bladder cuff.” That most diagnoses are made in people at least 70 years old complicates their treatment as well, as many of them have compromised kidney functionality, and major surgery may result in additional complications.

Over the past decade, commercial per-member per-month (PMPM) drug spend under the medical benefit has almost doubled, according to Magellan Rx Management, a division of Magellan Health, Inc.

The company just released the 10th edition of its Medical Pharmacy Trend Report, which also found that 61% of payers were concerned with their medical benefit spend, up from 32% of payers who said this in the inaugural edition of the report.

With numerous hospitals focused on the COVID-19 pandemic and many areas under stay-at-home mandates, home infusion is more important than ever. Changes within the industry already have been seen, and the current situation is likely to result in permanent shifts within the home infusion space.

“If you can do infusion at home, you need to do it there,” maintains Ashraf Shehata, KPMG national sector leader for Healthcare & Life Sciences. “This is about controlling infection risk in the near term, and many home infusion candidates are in a high-risk category. Longer term, there has been a shift toward delivering care in the most economical and clinically appropriate setting, largely driven by payers.”