Three Minutes with April Kunze, Senior Director of Clinical Program Development

Hear about how Prime finds savings in Blue + Prime alignment and a total drug managment strategy

June 18, 2021
April Kunze manages Prime’s formulary development process. She oversees the various internal committees involved in formulary development and helps create clinical and financial decision-making models. She works closely with Prime’s Trade Relations, Account Management, Specialty Solutions and Clinical Solutions departments to determine the most clinically robust and cost-effective decisions. Formulary recommendations are presented quarterly to the Prime Therapeutics Pharmacy & Therapeutics (P&T) Committee and Business Committee(s). April joined Prime in 2004.

What trends are you watching with regards to drugs and the U.S. health care system?

I see a number of big trends.

First, continued rise of specialty drugs and drugs that treat rare diseases. Most of them cost well over $150,000 per year. Many of these new drug approvals are “me too” drugs. (“Me too” or “follow-on” drugs are similar to a drug that’s already available.) These create an opportunity for preferred products in the specialty space. Other new drugs are treatments for very rare diseases that most people are unfamiliar with. We have an opportunity to provide clinical information and to help manage treatments for these conditions.

Second, gene and cell therapies will continue to proliferate. We are seeing that these therapies can cost more than $2 million. Medical drug integration is critical. We have to manage these drugs from both the medical and the pharmacy benefit side, because many of these treatments are administered in a hospital setting. Fortunately, Prime has the ability to do total drug management.

And third, there are more digital health solutions to manage disease states versus using drugs only. (Digital health refers to the use of information and communications technologies – both hardware and software – in health care.) We know that our health plan clients are very interested in how digital health applications can help their members, and Prime is actively developing strategies to meet this emerging therapy.

What differentiates Prime from its competitors in how it monitors the drug pipeline?

We cover the basics, of course. We review newly approved drugs, recent drug launches, generic updates, new indications and news of note on drugs in the approval process.

But where we excel is in our review of potential high-cost drugs in the pipeline. We arm our health care clients with timely, highly accurate forecasts for use and costs along with actionable strategies to improve drug management.

Because Prime has medical claims data, we can look at diagnosis codes and find out how many members actually have a specific condition. Our forecasting of the potential use of a new drug is more specific than just using population estimates.

Prime is working with an approximately 17-million-member commercial, Medicaid and Medicare medical and pharmacy claims database.

The value of forecasting based on that is invaluable. It’s the difference between saying – ‘a drug’s annual U.S. sales are projected to be $81 billion dollars’ and ‘the impact to your drug spend based on your data will be $0.04 per member per month.

How quickly do you think plans, providers and patients will adopt use of biosimilars?

Prime has seen great interest in biosimilars over the past year. The market across the U.S. is changing. Market dynamics are more favorable for biosimilar uptake. Prime has already had great success. For example, one of our health plan clients recently moved from Rituxan® to its available biosimilars. That client increased its biosimilar market share to greater than 80% and saw $0.24 PMPM in savings within six months.

What is Prime’s Medical Business Committee (MBC)? What does it do?

These are quarterly meetings with our health plan clients to discuss medical drug spend and strategies to manage this spend. The meetings have been virtual now, since COVID-19, and that’s worked out very well. We have retained good participation and input.

Our team identifies opportunities to increase value for our health plan clients. We set the strategy, develop messages and slide content. After we present at the MBC, our health plan clients make their decisions on implementation and timelines. Opportunities may include medical drug policy, biosimilar strategy, site of care, reimbursement contract analysis and much more.

Once decisions are implemented, Prime can measure the impact of the results within a year and present back to the group.

You work with Prime’s P&T Committee. What’s been the biggest change in formularies in the last 10-15 years?

The biggest change happened around 2017 with the launch of NetResults formulary. We worked very hard to figure out which drugs could be excluded while still focusing on quality care. It challenged us to think about how we leverage alternatives.

And with Prime’s analytics, we can show how a narrow formulary can deliver significant pharmacy savings ($11-14 PMPM) with no increase to medical costs.

We make decisions that are in the best interests of our health plan clients and members based on the clinical evidence, data analytics and competitive trade agreements. We collaborate closely with our health plan clients to align to a formulary strategy that maximizes value.

Creating a standardized national formulary was key to helping us leverage better contracts with pharma. This brought a lot of financial value to Prime and our health plan clients and has helped them keep costs down for members too.

Significant gains in Blue+Prime alignment were made in the development of NetResults. That strategic collaboration helped pave the way for the recent launch of MedDrive™. That’s our new medical drug management program aimed at helping our health plan clients manage the high costs of medical drugs.

You can see the origins of MedDrive in all of these areas – NetResults, our forecasting expertise, pipeline management, biosimilar recommendations and more. We’ve been building toward this for many years.

The first phase of MedDrive focuses on drug savings through greater biosimilar drug adoption, most of which are paid on the medical benefit. Our drug management solution helps health plans drive greater adoption of biosimilars. At prices 15%-30% lower than reference products, biosimilars provide therapeutic benefit while helping to lower costs.

MedDrive also includes benefit designs that prefer lowest net cost non-biosimilar drugs, plus enhancements to predictive data analytics, medical sourcing opportunities, and consultation services.

It’s an exciting and important time to really make a difference in this industry.

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