Prime’s Rae McMahan reveals winning strategies for total drug management
Prime manages evolving drug therapy landscape using powerful levers on both pharmacy, medical benefit
September 26, 2019
Sixty-one percent of employer groups say managing specialty drug cost is their top concern.¹ It’s understandable, given spending has shifted from traditional to specialty medicines, which now account for nearly 50% of total drug spend, or $407 of the $876 per person per year (PPPY) spent on medicines.² And managing drugs covered on either the pharmacy or medical benefit is complex. McMahan said, “It’s taken time for this issue to rise to the top for employer groups. The key to successfully managing the high costs is a holistic approach to managing the cost and use of high-cost therapies across both benefits.”
Prime’s holistic approach to managing specialty drugs means integrating and aligning with Blue plans. This approach allows Prime to manage specialty therapies differently from its competitors. Appropriate management of drugs covered under the medical benefit is especially important because about 40% of these newer treatments are now paid for with the medical benefit. For example, Prime’s innovative Site of Care program identifies when drugs may be administered at a different location that’s equally safe but at a much lower cost. It’s one way Prime helps clients make coverage decisions to reduce specialty costs while still delivering optimal patient outcomes.
“Specialty drugs have evolved significantly over the past five years. We used to consider a $10,000 annual treatment to be high-cost, now million-dollar treatments exist. As a total drug management company, we use every lever we have, from medical and pharmacy formulary management to avoiding unnecessary medical costs to value-based agreements with drug manufacturers that return some of the investment if the treatment doesn’t work. We know some facilities and providers are costlier, so we favor reasonable reimbursement, meaning our goal is for members to receive the best quality of care, where we factor in the value of that care relative to its cost.”
On the pharmacy benefit side, Prime’s Split Fill program allows an individual who is new to therapy to fill only part of a prescription to save money and reduce waste. Prime’s health plan clients can save an average of over $700 on certain oral oncology medications under the Split Fill product. “Our goal is to reduce waste with high-cost therapies and we see an opportunity to expand this program beyond oncology,” said McMahan.
Another layer making specialty drug management complex is medical drug claims don’t process in real time. To get ahead of drug misuse and waste, Prime developed its Medical Claims Edits program – a library of drug-specific rules designed to show when medical drug use is out of line with expected cost, quantity and use. The claim edit program also helps identify prior authorizations that are handled in an inappropriate way.
Prime leverages its reporting and analytics capabilities by deploying Specialty Monitor™, an industry leading integrated data solution that delivers specific medical and pharmacy benefits insights to its health plan clients. This automated method is different from other PBMs. Powered by Artemetrx, this self-service tool provides near-real-time access to drug use, cost and trend information that allows health plans to make informed business decisions in the moment. “Our Blue plans use Specialty Monitor to drill down into prescribing patterns,” said McMahan. “Medical data can be messy and this tool aggregates the data in a meaningful way that allows plans to take action and quickly implement real management strategies to care for their members, without a span of weeks or months slipping by.”
Also, Prime established a unique Specialty Drug Strategy Committee (SDSC), a cross-functional expert team that meets quarterly with Prime clients to highlight, review, and discuss relevant and trending topics in specialty drug management. The committee reviews cost management programs and strategies and shares therapeutic class disease expertise and actionable client-specific medical and pharmacy analyses. For instance, SDSC findings showed an estimated $5 million savings opportunity by optimizing the dose of two drugs used to treat a small number of individuals with the rare disease, hereditary angioedema (HAE).
Lastly, McMahan discussed management of orphan and ultra-rare diseases, for which there is a rapidly growing pipeline of therapies. Many new therapies for this relatively small group of individuals – 20,000-200,000 in the U.S. – are first-time treatments where none had previously existed, or cures. Some are one-time (gene) or curative therapies, and annual drug therapy cost for ultra-rare disease therapies range from $250,000 to over $1 million. “We need to consider different strategies for managing these groundbreaking therapies,” said McMahan. “We’re expecting 20-30 new gene therapies in the next few years with up to $5 million price tags, and we need to help health plans and employers prepare how to pay for them. And all stakeholders need to work together to manage the rapidly evolving impact of specialty therapies.”
- Pharmacy Benefit Management Institute 2018 Trends in Specialty Drug Benefits. March 2018.
- Medicine Use and Spending in the U.S. IQVIA Institute. April 2018.
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