Tips for Addressing the Medical Pharmacy Benefit Spend

A total of 49 specialty drugs were approved in 2018: 25 managed through the medical benefit, 19 through the pharmacy benefit, and five through both. During a presentation at the AMCP Annual Meeting, Eric McKinley, PharmD, director of medical pharmacy strategy at Magellan Rx in Brandon, Mississippi, and Carly Rodriguez, PharmD, pharmacy director of clinical innovation at Moda Health in Portland, Oregon, discussed the increasing specialty pharmacy spend and opportunities to manage medical pharmacy benefit.

Dr. McKinley began by discussing cost trends in specialty pharmacy. Between 2013 and 2017, medical pharmacy per-member, per-month (PMPM) commercial costs increased by 68%. During this time, medical pharmacy PMPM Medicare costs increased by 22%. Between 2016 and 2017, the treatment category that saw the highest PMPM commercial increase was antihemophilic factor therapy (62%). During this time, the highest PMPM Medicare increase was for ophthalmic injection agents (20%).

Dr. Rodriguez then discussed more about Moda, which offers service in Oregon, Washington, and Alaska, covering approximately 400,000 medical lives and 1.1 million pharmacy lives. Moda realized the need for medical pharmacy management, as trends were continuing to increase (by 17.7% from 2013 to 2014). Moda uses prior authorization, post-service claims edits, site of service, dose optimization, and includes a biosimilar strategy for managing the medical pharmacy benefit.

She discussed some specific from Moda programs implemented to control spending. One is a drug wastage program that seeks to reduce waste associated with injectable drugs due to limited vial size availability. The scope of the program included 16 drugs that were high cost, had multiple vial sizes, and ranged in dosing. The program identified authorizations and evaluated whether rounding down to within 10% of the requested dose would allow for more efficient vial size. The program resulted in an annualized savings of $648,000.

In another program, Moda assessed site of care costs for 30 medications across the autoimmune, enzyme replacement, amyotrophic lateral sclerosis, immunodeficiency, and HIV drug classes. They collaborated with Magellan Rx to leverage their current capabilities, build mandatory requirements, and create policy elements. This resulted in approximately $3 million in savings. Dr. Rodriguez described a patient success story with site of care switching: A 26-year-old patients had Crohn’s disease and was treated with infliximab. The patient had a history of receiving infusions at the local hospital. The Magellan infusion referral nurse coordinated home infusions for the member, who said the home infusion went “great” and “wished” this was implemented years ago.

Presentation M7: Strategies for Staying Ahead of Specialty Drug Trends: Focus on the Medical Pharmacy Benefit. AMCP Annual Meeting 2019.