One of the greatest challenges in managed care is staying up-to-date on the constantly evolving healthcare landscape. This can be especially overwhelming for high cost, complex specialty disease states. Payers are often faced with making difficult coverage decisions for hundreds of disease states as they also juggle prioritizing daily job tasks, such as managing drug spend, developing clinical programs and policies, and implementing member engagement strategies. In face of this challenge, payers have reported difficulties handling drug requests for complex treatments, particularly for off-label use for specialty drugs in high cost, rare disease categories, which are poorly understood and have limited clinical guidelines.

To address this unmet need, some payers seek the assistance of key opinion leaders (KOLs), also known as thought leaders. KOLs are considered experts in their respective fields, are regularly sought out by their colleagues for opinions or advice, are early adopters of new treatments or procedures, establish best practice protocols for patient care, and many managed care organizations depend on them to better understand specific disease states and new therapies.

As part of its value-based approach to medical and pharmacy benefit management, Magellan Rx Management has developed an Expert Clinical Network (ECN) of local, national, and world-renowned experts and has access to more than 120 key thought leaders in several disease categories, including rare disease such as hereditary angioedema, hemophilia, oncology, and more. These experts assist clients with challenging prior authorization case reviews, peer-to-peer discussions, drug policy development, and formulary guidance. Ultimately, the ECN offers health plans and providers the opportunity to make a more informed decision that leads to positive patient outcomes.

One case study from the ECN program was for a request from a client to review a complex prior authorization case. The request was for prophylaxis therapy in a patient who was currently using Firazyr for angioedema. The KOL provided an evidence-based recommendation based on patient’s medical history and current burden of disease. The KOL did not believe the patient was an appropriate candidate for prophylaxis therapy which resulted in the patient being referred to a center of excellence for additional evaluation and a potential cost avoidance of $44,000 per month.

As payers are faced with making difficult clinical coverage decisions for hundreds of disease states, assistance from a KOL can help in the reduction of inappropriate medication use, while offering the highest value and quality of care in disease management. To learn more download a copy of our MRx Report.