Download A Proactive Approach to Specialty Management

Clinical Notes
A Proactive Approach to
Specialty Management
Specialty drugs are products used to treat complex chronic conditions such as
cancer, rheumatoid arthritis, HIV, and multiple sclerosis. While they are usually
associated with increased patient quality of life, better disease management, and
in some cases, cures, specialty drugs are expensive therapies that are catching
the attention of key stakeholders, such as payers and providers.
Industry trend reports over the past few years have demonstrated that specialty
drugs have been and will continue to be the fastest growing segment of drug
spend under the prescription benefit. This growth has created a ripple effect,
impacting patients and employer groups, inducing a financial strain on the overall
healthcare system, and placing added responsibility on payers. Now more than
ever, Pharmacy benefit managers (PBMs) are tasked with developing effective
cost-containment solutions.
Specialty Drug
Spend Continues
to Grow
Industry trend reports over
the past few years have
demonstrated that specialty
drugs have been and will
continue to be the fastest
growing segment of drug
spend under the prescription
benefit.
Best-In-Class (BIC) SpecialtyRx
To accomplish a cost-effective specialty drug benefit, MedTrak’s philosophy is to
be proactive vs. reactionary in the dynamic landscape of specialty drugs. The
implementation of the Best-In-Class or “BIC” SpecialtyRx Program has proven to
be one of the most successful offerings within MedTrak’s Clinical Suite of
Programs.
PA criteria developed internally
Evidence-based guidelines
FDA labeling
Ownership of PA
New-to-Market
coverage policy
Comprehensive approach Manages appropriate
medication use while
minimizing unnecessary costs
to our plans
MedTrak Services | 7101 College Blvd., Ste. 1000 | Overland Park, KS 66210 | 1.800.894.0794 | www.medtrakservices.com
Specialty Management (continued)
Prior Authorization Process
The first layer of a cost-effective specialty drug benefit includes the development and maintenance of solid prior
authorization criteria. All specialty medications are subject to review, in order to ensure that Plan Sponsors are
not exposed to unnecessary costs. MedTrak’s CCC is tasked with and constantly strives to be on the cutting
edge of information coming out of clinical trials, consensus guidelines, and other bodies of evidence guiding the
most appropriate use of medication therapy.
In addition, MedTrak has implemented a New-to-Market drug coverage policy. New-to-market products and
new variations of products already in the marketplace will be excluded from benefit coverage until the product
has been evaluated, deemed clinically appropriate, considered cost effective, and assessed for place in
therapy. In order to allow adequate time for the CCC to perform a full evaluation, it is MedTrak’s policy that new
drug entities not be eligible for benefit coverage for a period of 90 days after market entry. Requests for
coverage made prior to 90 days after market entry will be declined.
This strategy helps to minimize costs and provide evidence-based decisions and recommendations. It’s a
comprehensive approach to managing appropriate medication use by optimizing care and outcomes for our
members and minimizing unnecessary costs for our Plans.
Preferred Product Programs and Formulary Management
Preferred product programs help to increase the market share of drug products that are more cost-effective
than others within the same therapeutic category and successfully leverage significant discounts to pass along
to Clients. MedTrak has preferred product opportunities within the following drug categories:



Growth Hormone
Inflammatory Conditions
Hepatitis C
Clients also have the option of selecting various formulary options, to further incentivize members to use
preferred formulary alternative therapies over non-preferred or excluded products, thereby enhancing
opportunity for additional savings and rebates back to the Client.
Waste Management
In addition to standard limitations being applied to specialty drug approvals, such as day supply limits, quantity
limits and max dollar limits, MedTrak’s Clinical Care Center has also implemented two other waste
management strategies:


Oncology Split-Fill Program
Hemophilia Assay-Management Program
Due to the frequency of side effects and discontinuation rates associated with certain
chemotherapy medications, MedTrak has implemented a Oncology Split-Fill Program. The
primary purpose of this program is to avoid unnecessary waste and therefore unnecessary
costs to both Members and Plans due to early discontinuation of any of these medications.
MedTrak Services | 7101 College Blvd., Ste. 1000 | Overland Park, KS 66210 | 1.800.894.0794 | www.medtrakservices.com
Specialty Management (continued)
With this program, a Prior Authorization has been entered to allow up to 2week supplies of drug for 12 weeks. The members’ co-payments are adjusted
proportionally. Members and physicians are informed of the approval and the
Split Fill Program. After this trial period, claims can then be submitted for
original quantity.
Other BIC Specialty Rx Programs
MedTrak Services offers other customized cost savings solutions for Plan
Sponsors through the following specialty program enhancements:

Assay and Inventory Management Program. By administering
hemophilia benefits through this program, MedTrak guarantees that
the blood clotting factors dispensed for a particular member will
always be within ±3% of the written prescription.

Medical Drug Channel Management. This program redirects select
specialty medications associated with a J-Code (for medical billing
purposes) to the prescription benefit for processing, thereby
providing an opportunity for substantial savings to our Clients
Case Study
In a recent analysis of the Oncology Split-Fill Program, fifteen patients prematurely discontinued treatment on
odd fill dates, which resulted in substantial savings to the plans.
For more information about MedTrak Best-In-Class SpecialtyRx Program, contact your MedTrak Account
Manager to discuss your Plan’s specific statistics and cost management strategies.
References:
1.
2.
3.
4.
HIRC Specialty Pharmacy Provider Landscape 2012. Accessed August 20, 2015.
IMS Health White Paper. Succeeding In the Rapidly Changing U.S. Specialty Market 2014. Accessed
August 20, 2015.
EMD Serono Specialty Digest, 11th edition. Accessed August 20, 2015.
The 2014 Drug Trend Report. The Express Scripts Lab. Accessed August 20, 2015.
MedTrak Services | 7101 College Blvd., Ste. 1000 | Overland Park, KS 66210 | 1.800.894.0794 | www.medtrakservices.com