October is American Pharmacists Month and an excellent opportunity for us to celebrate all of our Magellan Rx pharmacy heroes that help our members live healthy, vibrant lives! To kick off American Pharmacists Month, we wanted to shine a spotlight on our two pharmacy residents. We will be taking you behind the scenes to find out what got them interested in pharmacy and what they love most about their residency program.

Magellan Rx: Why did you decide you wanted to become a pharmacist?

Shyra Bias, PharmD: I decided at a young age that I wanted to be the drug expert in my family after witnessing a family member suffer from the complications of extremely uncontrolled latent autoimmune diabetes in adults (LADA). My desire to help my family led to a passion to improve many patients’ lives by ensuring that they can receive the medications they need at a cost they can afford.

Alaka’i Montalbo, PharmD: Growing up, I played a lot of sports and was always in the gym. As an athlete, you learn about sports supplements and how they can help you. In high school, I loved diving into the science of supplements. I later learned in life that the “science” of supplements was not backed by clinical data. After having my dreams crushed, I was working in the hospital and one of the nurses asked me if I had ever considered being a pharmacist? She knew I enjoyed talking about supplements and learning how different medications worked in the body. After researching what pharmacists do, I realized this was exactly what I wanted to do, and I have not looked back since.

Magellan Rx: What advice would you give to someone who wants to become a pharmacist?

Shyra Bias, PharmD: Keep your eye on the prize! The road to PharmD is not an easy one, but if you are truly passionate about the profession, you will get through it. Also, pharmacy is a very small world, so be intentional about making connections because you never know who may be able to change the trajectory of your career.

Alaka’i Montalbo, PharmD: Find joy in your journey. While pharmacy school is a long journey, it will fly by in the grand scheme of life. Don’t give up and never stop believing that you can do it. Don’t fall into the trap of saying to yourself I’m not ready yet. Right now, start making connections with pharmacists and current pharmacy students.

Magellan Rx: What different career paths can you do as a PharmD?

Shyra Bias, PharmD: There are many options for Pharmacists; many do not come to mind immediately when someone thinks of the traditional roles of a pharmacist. Some of the first paths that come to my mind include industry pharmacy, nuclear pharmacy, managed care pharmacy, and clinical pharmacy (hospital setting) to name a few.

Alaka’i Montalbo, PharmD: During pharmacy school, I had the opportunity to go to local high schools and talk about the profession of pharmacy. There are so many different careers Pharmacists can choose and every route is unique. There are traditional roles like retail, hospital pharmacy, and then some non-traditional roles are academia, nuclear (chemotherapy) pharmacy, FDA pharmacists, and Indian health services.

Magellan Rx: What made you choose managed care pharmacy?

Shyra Bias, PharmD: I chose managed care because I really enjoy the population health aspect of the industry. It gives me a true feeling of gratitude to change millions of lives with “the click of a button.”

Alaka’i Montalbo, PharmD: Managed care is the perfect balance between using clinical data and real-world efficacy to help patients manage their disease states. One of my favorite quotes about pharmacy is from Everett Koop, “Drugs don’t work in patients who don’t take them.” I would add to this quote, also with patients who can’t afford them. Managed care is that perfect bridge between both worlds of pharmacy, and I feel like I am making a huge difference every day, not just for one patient but for entire populations.

Magellan Rx: How do you like your residency at Magellan Rx?

Shyra Bias, PharmD: I am grateful beyond words to have been matched with Magellan Rx. The company culture makes me feel extremely welcomed, and the variety of experiences that we are exposed to through our rotations will allow us to succeed no matter where I end up in the managed care industry.

Alaka’i Montalbo, PharmD: Being Native Hawaiian, Ohana (family) means everything to me, and family means no one gets left behind or forgotten. Magellan Rx is one big Ohana and every day, I get to stand on the shoulders of giants. I feel so blessed to be a part of this company and everyone in this residency program is always willing to stop what they are doing, take time out of their busy schedules to help me grow! I cannot express my gratitude enough and I look forward to paying it forward in my career.

Don’t forget to follow us on LinkedIn and Twitter where we will be featuring different pharmacists and pharmacy techs throughout October. #MRxAmericanPharmacistMonth

As I started my career with a passion to add value to the healthcare industry, I would never have been able to predict the rapid evolution we are experiencing today. Take, for example, specialty pharmacy. What originated nearly 50 years ago as a treatment solution for just a handful of conditions has grown exponentially into a $250 billion industry now treating hundreds of ultra-rare conditions and orphan diseases. The explosive growth of the specialty pipeline, combined with the high cost and complexity of managing specialty patients (who often have at least one other chronic condition or comorbidity), highlights the need for payers to stay ahead of the trend and deploy targeted, future-focused management strategies for better specialty drug management.

Tracking the Trends

In 2008, there were eight specialty drugs approved by the FDA; compare that to 2020 with 53 total specialty drugs, and half of those approved for medical benefit use. Not only are the number and scope of specialty drugs increasing, but so are costs. So far in 2021, five high-cost therapies have been approved with price tags of $400K to nearly $750K—this is the new normal. As high-cost and potentially life-saving drugs continue to enter the market, it becomes more and more difficult to determine which patients should receive them and how they will be paid for.

In 2012, about one-quarter of total pharmacy spend was attributed to specialty drugs; in 2020, we have reached 50%. When you drill down even more, about half of that spend occurs on the medical benefit. Going deeper, oncology remains the top driver when it comes to overall medical benefit costs as the highest-spend category for the past 11 years—representing nearly 50% of total per-member-per-month spend for the Commercial line of business and over 60% for Medicare.¹ How can employers and payers keep track of these evolving market dynamics?

The Power of Magellan Rx Excellence

At Magellan Rx Management, we have nearly two decades of experience creating flexible solutions that allow our customers to improve patient care, stay ahead of trends, and reduce specialty spend across both the traditional pharmacy and medical benefits. As the original experts in medical pharmacy management, we have a deep understanding of the trends and demonstrate our commitment to advance thought leadership in this space with the annual Magellan Rx Management Medical Pharmacy Trend Report^TM. This Report is a one-of-a-kind resource that highlights key areas of spend and trend across commercial, Medicare, and Medicaid lines of business as well as management strategies for new and emerging therapies.

We also leverage our Expert Clinical Network of more than 175 key opinion leaders (KOLs) across multiple disease states that participate in peer-to-peer discussions and guide recommendations for patients with complex and hard-to-treat conditions. This is especially helpful for payers who lack in-house expertise in ultra-rare and orphan conditions as we work to secure specially matched, unbiased KOLs that are affiliated with major healthcare treatment centers nationwide.

And we don’t shy away from the hard stuff. Our legacy is solving complex pharmacy challenges and meeting the momentum of new developments head-on. In fact, that is what makes us stand apart from other PBMs—our integrated approach and account service model is designed to encourage innovation across clinical, formulary design, distribution channels, and medical pharmacy strategies. These unique solutions are prioritized and intrinsic to the value we bring as a partner.

• Medical Pharmacy Solutions with coordinated management across all sites of service, including utilization management support.
• Formulary Strategies for both traditional and medical pharmacy drugs that connect best-in-class formulary management and value-driven rebate solutions with clinical policies and medical pharmacy programs to manage costs.
• Specialty Pharmacy Distribution that takes a patient-centric, clinical approach to drive adherence and improve outcomes, along with cost avoidance and cost management solutions to reduce total cost of care.
• Condition-specific Programs that deliver better health outcomes and improved CMS STAR ratings.

One example of our devotion to excellence is the work we have done in preparation for the market entrance of oncology biosimilars. We started building the foundation in the autoimmune category and continued to refine our methodology, working hands-on with payers and pharma to create a solution that is not passive but evolves with the dynamic market. As such, our customers were able educate their providers and members prior to the availability of oncology biosimilars. Our impact? We’ve delivered over $40 million in annualized savings for early adopter health plans.

Unlock the Possibilities

I am proud to lead a team of industry experts and thought leaders who inspire me every day to challenge the status quo and add value to this complex area of healthcare spend. I would never have guessed that fifteen years post pharmacy school would have led me to where I am now, but I couldn’t be more grateful. Our team is poised to answer the industry’s toughest questions with thoughtful, clinically-focused solutions—and I’m confident we’re already prepared for the next wave of change. It’s in the spirit of our people to push the industry forward, and I take pride that we have the right experts collaborating with our customers to develop proven programs that drive real results.

Are rising specialty costs a concern? Let’s connect on how we can help solve your unique population’s needs. We’re here for you.

1. Magellan Rx Management Medical Pharmacy Trend Report™, 11^th Edition, © 2021

“These [medical pharmacy] trends continue to be a challenge for all stakeholders involved in the care of patients with complex specialty conditions, making it vital for them to stay current and informed for better decision-making,” said Kristen Reimers, RPh, senior vice president, specialty clinical solutions, Magellan Rx Management.

Medical benefit drug spend, or what we call medical pharmacy, continues to be one of the largest cost drivers when it comes to overall specialty drug trends. At Magellan Rx, we have nearly 20 years of experience in managing this high-cost and complex portion of medical pharmacy spend and have published the industry’s only detailed source for trends related to medical pharmacy for the last 11 years.

Here are the trends you need to know from the eleventh edition of the Medical Pharmacy Trend Report:¹

1. Commercial per-member-per-month (PMPM) spend has increased 89% from 2009 to 2019.
2. Medicare remains the highest spend and utilization line of business (LOB) with 10% of members having a medical drug claim.
3. The average annual cost per member for the top 10 drugs is almost $45,000 for Commercial members.
4. For medical specialty drugs 30% of members are driving 96% of the spend.
5. Gene therapy is the top concern for payers in medical pharmacy.
6. Oncology remains #1 highest-spend category across all LOBs.
7. The oncology pipeline is forecasted to increase 105% in PMPM spend from $52 in 2019 to $106 in 2024.
8. There’s a new top five drug list for commercial: Remicade, Neulasta, Ocrevus, Herceptin, Avastin, with Ocrevus entering the top 5 and having an 85% trend.
9. The highest-cost medical benefit drugs exceed $1M per patient per year.
10. Biosimilars Renflexis and Inflectra (in the BDAIDs category) market share increased 4-6 percentage points for commercial and Medicare and a substantial 24 percentage points for Medicaid.

Want to dig into these trends and more, including the latest in management strategies to combat rising pharmacy trend? Download your copy of the report.

1. Unlock the Latest Trends and Emerging Strategies to Manage Rising Medical Benefit Specialty Drug Spend.” Magellan Rx Management Press Release, 20 May 2021. Accessed May 20, 2021.
2. 2020 Magellan Rx Management Medical Pharmacy Trend Report™, © 2021.

The Role of Precision Medicine in Oncology Care

The approach to cancer treatment has been transformed dramatically over the last decade. The use of medications to treat cancer is shifting from a “one size fits all” approach to more personalized therapies. The individual patient’s specific tumor characteristics may now drive the selection of the best treatment option. Identification of these tumor characteristics is often accomplished through genomic testing. Because clinical data regarding genomic testing is being published at an unprecedented pace, both providers and payers may struggle to keep up and need access to a shared, unbiased decision-support technology to ensure patients are receiving optimal treatment options.

How can you accurately approve tests and treatments while at the same time streamlining the prior authorization processes?  Here are four ways:

1. Follow evidence-based standards – there are many different lab companies who offer genomic testing as well as variations in the testing products offered by many labs. Clinical decision support for genomic testing assures that that each molecular test ordered meets clinical, evidence-supported standards and also ensures the use of cost-efficient testing. When physicians utilize this clinical decision support to order genomic testing, it streamlines and optimizes prior authorization and reimbursement arrangements with health plans
2. Enable transparency – provide a real-time window into the precision medicine decision-making process. Currently, it is difficult to ensure that all patients who could benefit genomic testing are receiving appropriate testing. When health plans have access to real-time genomic testing results, quality initiatives can be designed to track appropriate care interventions.
3. Take a patient-centered approach – ensure patients get the most appropriate tests from preferred labs at the right time in their treatment journey. Patients are understandably anxious awaiting test results and a system that streamlines workflow for practices and expedites the delivery of test results ensures appropriate, quality care for patients when time matters most.
4. Promote collaboration – ensuring scalable, appropriate use of precision medicine for cancer means working collaboratively with oncologists and molecular testing labs. Cancer care is often fragmented and solutions are needed that align all stakeholders while keeping the patient at the center of the solution. Providing clinical decision support for genomic testing as well as corresponding drug selection allows for all parties to work quickly and efficiently in order to maximize coordinated, quality cancer care.

To learn more about Magellan Rx Management’s approach to precision medicine in collaboration with Trapelo Health, click here.

As a market leader and disruptor in specialty drug management, Magellan Rx Management has been delivering targeted and innovative solutions for over 16 years to help health plans reduce specialty drug costs on the medical benefit while maintaining a high quality of care for their members. Our suite of solutions can help plans develop customizable, flexible programs to meet some of their toughest challenges.

• Prior authorization: Ensures complex and high-cost drugs are prescribed according to evidence-based policies.
• Post-service pre-payment claims edits: Assures medical benefit drugs are paid correctly.
• Provider network strategy: Encourages lower-cost but equally effective agents through a variable fee schedule.
• Site of service management: Guides medical injectable drug administration to lower-cost and clinically appropriate site of care.
• Medical formulary management: Enhances management of medical drug classes to promote the most cost-effective therapies

Why medical pharmacy management matters

With specialty drug costs accounting for nearly half of total drug spend, health plans continue to look for better ways to manage those rising costs while staying ahead of ever-changing market dynamics (like emerging therapies for rare and orphan diseases and new-to-market biosimilars). Specialty drugs administered by healthcare professionals (typically in a provider’s office, hospital outpatient facility, or through home infusion) are paid under the medical benefit—or what we like to call “medical pharmacy”—and remain a leading driver of rising costs. In fact, according to our research, the latest five-year per-member-per-month (PMPM) trend for medical pharmacy spend was 65% in Commercial, 40% in Medicare, and 78% in Medicaid.

A real-life customized solution

One of our health plan customers with a mix of Commercial, Medicare & Medicaid lives was beginning to see significant utilization in specialty medications. They turned to Magellan Rx’s clinical and pharmacy trend experts, who analyzed trend drivers, recommended a multi-pronged approach to management based on their unique data, and collaborated with the plan to implement several programs to maximize effectiveness and meet plan goals including innovative strategies such as a drug wastage solution.

So, what are the results?

Our health plan partner realized a cost reduction in just one year by implementing a suite of solutions alongside our team of medical pharmacy experts—resulting in a nine percent decrease in medical drug spend! Based on this particular’s plan size and benefit design, each solution contributed demonstrably to overall savings.

Individual program implementation is dependent on plan size and other factors. These flexible solutions can also operate outside of the traditional payer-PBM relationship. Now, you can plug in to the extensive clinical expertise and experience at Magellan Rx by delegating specialty and medical drug management services while retaining a separate pharmacy benefit manager.

Are you looking for a customizable, flexible solution to combat rising specialty spend? Connect with us today!

In January 2021, the United States (US) Food and Drug Administration’s (FDA) Center for Drug Evaluation and Research (CDER) published Advancing Health through Innovation: New Drug Therapy Approvals 2020. This report provides a summary of a number of approvals and highlights the novel therapies approved in 2020, continuing the generally upward trend in approval volume seen over the past decade, despite the impact of coronavirus disease 2019 (COVID-19). Compared to 2018 and 2019, in which CDER approved 59 and 48 new drugs, respectively, 53 novel agents were approved in 2020. This number does not include new and expanded uses of already approved drugs, new formulations, new dosage forms, vaccines, blood products, cellular or gene therapy, or biosimilar approvals. Once again, the number of approvals exceeded the average of 41 novel approvals per year in the past 10 years. Figure 1 outlines approvals over the past 10 years.

Despite the ongoing pandemic the FDA continued their strategic initiatives to expedite the safe review of treatments in 2020. With the unprecedented challenges incurred in 2020, the FDA acknowledged that maintaining their commitment to bringing forth innovative therapies was difficult. Remarkably, the numbers reported by the FDA do not include the several emergency use authorizations (EUAs) issued by the FDA for COVID-19.

Last year, all 53 novel drug approvals again met their Prescription Drug User Fee Act (PDUFA) goal dates, cementing this as a priority for the Agency. In 2020, 40% were considered first-in-class, and 58% were approved for rare diseases (Orphan Drugs), the latter of which increased from 44% in 2019. Priority Review was granted to 57% of novel drugs, 23% received Accelerated Approval, 42% were designated as Breakthrough Therapy (up from 27% in 2019), and 32% garnered Fast Track designation. Overall, 68% of all drug approvals in 2020 used expedited development and review methods. In addition, 92% were approved in the first review cycle, and 75% were approved in the US prior to receiving approval in other countries. A breakdown of the types of drugs approved in 2020 is illustrated in Figure 2, with agents within the oncology spectrum representing over one-third of 2020’s novel approvals.

The notable 2020 approvals encompassed new advances for the treatment of infectious diseases, including a new medication class for the treatment of human immunodeficiency virus-1 (HIV-1). Garnering perhaps the most attention, the FDA also approved the first medication for hospitalized patients with COVID-19. Unique infectious diseases in the US also received attention, with a new drug for malaria, two new options for the Ebola virus, and a new treatment for Chagas disease approved in 2020. In the neurology arena, there were multiple approvals of agents for more common conditions, such as migraine or Parkinson’s disease. Moreover, there were significant advances for rare neurological conditions, including the first oral agent for spinal muscular atrophy and new treatments for rare seizure disorders. In addition, two immunological agents were approved for the treatment of neuromyelitis optica spectrum disorder. Additional treatment options emerged for several autoimmune conditions in 2020 as well. Not surprisingly, numerous advances were made within the oncology umbrella, including both novel approvals and new or expanded indications for several existing agents. With over half of the novel approvals being classified as Orphan Drugs, in 2020, the FDA has fortified their dedication to providing innovative and often targeted treatment options for all individuals.

Taking your medications exactly as prescribed (improving medication adherence) is one of the most important things you can do to enhance your health and prevent medical complications.

For many Americans, medication adherence can be difficult to maintain. There are a number of barriers that we face every day, from social determinants of health (like medication cost, the ability to get your medication, etc.) to simply remembering when and how often to take your prescription.

As part of your pharmacy care team, we are dedicated to helping you manage your medications so you can live a healthy life. Here are 5 tips for improving medication adherence:

1. Set a reminder: Forgetfulness is the leading cause of non-adherence. Set an alarm on your phone or use a weekly pill organizer to remember when to take your medication, and include a note on how to take your medication (on an empty stomach, with water, with food, etc.)
2. Understand your medication: Understand how your medication works and why it is important to take it as prescribed. Ask your physician or pharmacist follow-up questions about anything you don’t understand. The more you know, the more likely you are to stay on track.
3. Know what happens if you miss a dose: What happens when you don’t take your medication as prescribed? Sometimes it sets back your treatment or can cause adverse effects or symptoms. If you do miss a dose, reach out to your pharmacist! Follow up with them as soon as you remember to minimize negative effects and get back on track.
4. Know your options: We understand that medication can be expensive, but there are things you can do to help reduce the cost to you. Call your health plan to make sure you are using a preferred pharmacy or to find out what medication alternatives are covered and available. If applicable, talk to your pharmacist about filling a 90-day supply, sometimes this can cost less than a monthly refill.
5. Plan ahead for refills:Get into the habit of checking your bottle for the number of remaining refills. Most pharmacies will call your doctor for you when refills run out, but it’s always a good idea for you to know when your prescription is coming to an end.

Technological and scientific advancements have dramatically altered the treatment landscape in several disease states. These include orphan diseases and conditions that previously had no disease-modifying treatment options. These innovative therapies have also come with unprecedented costs, with some agents introduced at a price exceeding one million dollars for a single patient. Value-based purchasing arrangements (VBPs) have attempted to manage the initial cost of these agents. In a VBP, which is sometimes referred to as an outcome-based arrangement, the ultimate price that is paid for the drug is dependent on the clinical outcome. In addition to a plan’s traditional utilization management initiatives to maintain sustainability, this strategy aims to hold pharmaceutical manufacturers responsible for the result of their product. This is similar to other healthcare environments, such as when readmissions impact hospital reimbursement. Under VBPs, a pharmaceutical manufacturer would issue a reimbursement if their product failed to produce the desired clinical outcome. In addition, this strategy incentivizes the development of unique therapies that are more likely to have a clinically significant impact. Novel medications that improve outcomes would provide a greater healthcare value and could be priced higher in the market. Currently, volume is a large driver of cost, with discounts from pharmaceutical manufacturers often tied to the number of units dispensed. This is less helpful for niche-area pharmaceuticals and genuinely innovative treatments used for uncommon conditions.

Practical considerations of VBPs, such as a higher administrative burden (e.g., paperwork, electronic database access, automated retrieval of data), limit their application to all products. Since it can be expensive to measure outcomes in order to assess the worth of a product to an individual patient or plan, VBP concepts are most commonly applied only to the costliest medications. For instance, VBPs can have a significant impact on the pricing of agents like gene therapy or select oncology agents. Some of these agents can have a large clinical impact on disease progression, survival, or quality of life, but a drug may not have the same results in all patients. However, value-based or outcome-based pricing may provide an increased incentive to payers by decreasing their initial risk and providing more sustainable treatment coverage.

While there has been an increase in the use of VBPs by states, manufacturers, and other payers in order to control drug spending and tie patient outcomes to cost, uncertainty remains in developing novel VBPs. The Medicaid Drug Rebate Program (MDRP) created by Congress under the Omnibus Budget Reconciliation Act of 1990 ensures that Medicaid receives the lowest net price for a single source drug or innovator multiple source drug during the rebate period charged to any payer. Simply put, pricing net of all discounts, must be reported to Medicaid, and the best price would have to be offered to Medicaid as well. It is critical that Medicaid programs continue to receive the lowest price available for a single source drug or innovator multiple source drug.

On June 19, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that is aimed at promoting VBP flexibility for a variety of payers, including Medicaid, with a goal of maintaining a best price for Medicaid. CMS notes that best price creates challenges related to the availability of VBP arrangements. For example, under existing best price rules, if an individual fails to achieve the specified clinical outcome under the VBP arrangement, the drug manufacturer may be required to provide a discount or otherwise may not be entitled to payment for that patient. Thus, the best price of that drug for purposes of the MDRP could become zero. This possibility has stunted the development and proliferation of VBPs. This new proposal from CMS, which includes other regulatory revisions as well (e.g., minimum standards for Drug Utilization Review [DUR] programs), could ultimately lower healthcare costs and potentially limit spending on treatments with limited value over time.

The ultimate goal of a VBP is for all parties to have a vested interest in the outcomes of drug therapy and to share the risk related to healthcare costs. Specifically, it calls on manufacturers to have more “skin in the game.” Moreover, the change to the Medicaid market could have potential savings applicable to a variety of market segments, impacting all Americans. Regardless of the final outcome or any changes made to the current draft prior to its possible rollout, the proposal demonstrates readiness from CMS to pivot prior strategies to mitigate rising drug prices.