Jennifer Furhmann-Berger, PharmD, senior vice president, clinical services, at Benecard PBF, a pharmacy benefits administrator headquartered in Bonita Springs, Florida, believes in the power of communication. To overcome what she considers potential issues related to specialty drugs— such as fear of injections, lack of adherence, switching drugs but continuing to get both prescriptions, and improper drug storage—she says Benecard communicates with pharmacists and nurses to monitor these issues, along with potential side effects, and contacts physicians if non-adherence becomes a problem. “We are continually looking at claims and trends for safety and appropriateness issues,” she says.
She says Benecard relies on pharmacogenetics—not trial and error—to determine whether a patient can metabolize a drug or not. "If one doesn’t work, then we choose a different drug or dosage,” she says.
“We believe that putting the client at the center of care and pharmacists at the point of sale, enabled by clinical edits, keeps our trend down,” she says. Benecard manages specialty drug pricing by passing through the acquisition cost to payers, thus providing savings to plan sponsors.
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The company also works closely with plan sponsors to determine which drugs should be reimbursed through the medical versus the pharmacy benefit.
OptumRx uses a variety of strategies to manage the continuing high cost of specialty drugs:
1. Therapy solutions model. OptumRx provides patients with healthcare specialists and counselors who offer education and support via routine medication monitoring, personalized follow-ups, and in-home onboarding for patients new to treatment.
2. OptumRx’s oncology Split Fill program. Through the Split Fill program, OptumRx takes an individualized approach to patients who take cancer medications that may cause severe side effects by providing half a month's supply to patients for the first six fills. Pharmacy care providers check in with them early and often to manage potential clinical side effects, discontinuations, or adherence issues. In addition, pharmacy clinicians conduct regular drug utilization reviews and then notify a patient, caregiver, and provider of any recommended changes in dosage or medication.
Early results from these programs have shown 96% of enrolled patients are more likely to tolerate therapy. For those who don’t, OptumRx helps them through discontinuation, resulting in pharmacy savings of $2,500 per patient per year.
3. OptumRx’s PreCheck MyScript. The tool helps prescribing physicians identify alternative, equally effective treatments at a lower cost, view a patient’s drug coverage, and determine if prior authorization is required. To date, one out of five transactions with a recommended alternative resulted in the provider choosing an alternative drug, delivering significant cost savings for patients and payers, Zeglinski says.
Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.