What are some strategies for formulary management?
- Preferred/nonpreferred drugs. Most therapeutic classes of specialty drugs have numerous drugs available. Your plan should designate preferred drug status to certain specialty classes and follow up with aggressive provider detailing to maximize market share of the preferred agents.
- Step therapy. For example, Anti-TNF (tumor necrosis factor) drugs Enbrel and Humira are self-injectable drugs administered through the pharmacy benefit. Remicade is an office-based infusion administered under the medical benefit. All three drugs have common indications, notably rheumatoid arthritis and Crohn’s disease. Remicade has a variable dosing schedule and data show that patients using Remicade often have higher total costs than those using Enbrel or Humira. Instituting a step therapy requiring a self-injectable before Remicade has resulted in lower claim cost and higher rebates.
- Rebate opportunities. Companies are continually working to identify opportunities to increase rebates through preferred formulary status and/or step therapies.
How do specialty drugs affect patient care?
Members using specialty drugs are, by nature, high cost, and potentially high risk. They require a very member-centric, high-touch approach to managing their care. Every month, health insurance plans should contact members using specialty medications to assess therapy and arrange delivery of the next month’s medication. These calls help to ensure high compliance rates and desired clinical outcomes.
The contact by the insurance company should accomplish three things. Patient assessments are based on the specific condition. Data is shared with a case management team, allowing a unique collaboration between the specialty pharmacy and the health plan. In addition, co-pay assistance is often available. Many manufacturers of specialty drugs have programs designed to support members who may have difficulty meeting their cost-share obligations. As part of the health plan’s outreach, members are asked if there has been any change in household finances that might affect the ability to pay. If that is the case, they are connected with manufacturer programs that waive or reduce co-pays. These programs are becoming more valuable as more high-deductible plans continue to be popular and can also help Medicare Part D members through coverage gaps.
Finally, specialty medications are expensive, not always easy to use and often have side effects related to the drug or the administration of the drug. If a member is noncompliant for any reason, not only is the drug cost wasted but there exists the likelihood of increased disease complications.
A health plan’s monthly contact with members has been proven to deliver higher member compliance. The burgeoning specialty drug pipeline presents a challenge but also an opportunity. All management levers need to be employed in order to ensure appropriate use and acceptable cost.
Steven Marciniak is director of pharmacy for Priority Health. Reach him at (248) 324-2820 or [email protected].
