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!

The following is an excerpt from the 2018 Community Impact Report.

The MRx Cares program, developed by Magellan Rx Management, is one great example where we deliver – value and results!

Helping when life is complex

As a next-generation pharmacy benefit manager (PBM), Magellan Rx Management leans into the complex pharmacy challenges facing our members. One such challenge is specialty pharmacy. MRx  Cares is available to members who live with complex chronic conditions— like Crohn’s Disease, Cystic Fibrosis, HIV, Rheumatoid Arthritis and the aftermath of organ transplants—and are currently receiving their medication through Magellan Rx Specialty Pharmacy.

When members first fill a specialty medication, they are automatically enrolled in MRx Cares at no cost. Members receive an easy-to-understand welcome kit specific to their medications and conditions. Soon after, a personal health coach reaches out.

Our MRx Cares program offers a unique approach to member management with Motivational Interviewing-based health coaching. Motivational Interviewing is a counseling method that helps patients resolve ambivalent feelings and insecurities to find the internal motivation to change their behavior and meet their personal goals.
Providing personalized support from  caring experts

The MRx Cares program is led by specially trained nurses and pharmacists. These expert health coaches work closely, one on one, with each individual. Together, they develop a personalized care plan with achievable goals. The health coaches check in monthly, or more if needed, via calls, texts or video consultations.

Helping improve drug adherence

In addition to 24/7 access to nurses and pharmacists who understand the member’s situation, the program offers monthly refill reminders to improve drug adherence. The health coaches are also there to help if members need assistance with the cost of their medications. They can help connect members to opportunities for financial assistance and community support groups.In the most recent participant survey, 99% of respondents indicated they were highly satisfied with the benefits of MRx Cares and the services they receive.

Having type 2 diabetes can be overwhelming. The good news? While everyone’s treatment plan will be different, there’s a good chance you can manage your type 2 diabetes by making healthy choices. Convinced, but still struggling to work good choices into your real life? Start here for tips on treating type 2 diabetes.

The key to treating type 2 diabetes is to keep blood sugar levels controlled and in your target range.

All of the following help to lower blood sugar:

• Making healthy food choices. Try to manage the amount of carbohydrates you eat by spreading them out over the day.
• Losing weight, if you are overweight
• Getting regular exercise
• Taking medicines, if you need them

It’s also important to:

• See your doctor. Regular checkups are important to monitor your health.
• Test your blood sugar levels. You have a better chance of keeping your blood sugar in your target range if you know what your levels are from day to day.
• Keep high blood pressure and high cholesterol under control. This can help you lower your risk of heart and large blood vessel disease.
• Quit smoking. This can help you reduce your risk of heart disease and stroke.

It seems like a lot to do—especially at first. You might start with one or two changes. Focus on checking your blood sugar regularly and being active more often. Work on other tasks as you can.

It can be hard to accept that you have diabetes. It’s normal to feel sad or angry. You may even feel grief. Talking about your feelings can help. Your doctor or other health professionals can help you cope.

With a little support and guidance, patients with diabetes can live healthy, vibrant lives. Our Live Vibrantly: Diabetes care program helps manage all aspects of diabetes from improving wellness, diet, and exercise to optimizing medication use. To learn more about Live Vibrantly: Diabetes, click here.

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This document is for your information only. It is not meant to give medical advice. It should not be used to replace a visit with a provider. Magellan Health does not endorse other resources that may be mentioned here.

Precision medicine is the concept of tailoring disease treatment and prevention to account for differences in genetic, environmental, or even lifestyle factors specific to groups of people.¹ Precision medicine takes genetic and biochemical information unique to a group of patients and uses that information to develop more specific and streamlined medications or treatments. The goal is to ensure that each medication or treatment is best suited to treat the individual, resulting in decreased side effects and increased effectiveness.²

Precision vs Personalized Medicine

Although the terms precision medicine and personalized medicine are used interchangeably, there can be nuanced differences. The National Research Council (NRC) issued a statement saying that the term “personalized medicine” can refer to a treatment that may be completely individualized to a specific patient, which is not the true definition of precision medicine.³ The difference here is that precision medicine seeks to create treatments that are applicable to groups of individuals who meet certain characteristics. This is different from “personalized medicine,” which implies individualized treatments available for every unique patient.

Current Landscape

In 2015, the Precision Medicine Initiative (PMI) was launched, with $215 million dollars invested into precision medicine research.⁴ A new program was created—All of Us Research Program—which had the goal of recruiting 1 million Americans and creating a nationwide database for research.⁵ Other examples of precision medicine initiatives include the Geisinger Health System’s National Precision Health Initiative, the Partnership for Accelerating Cancer Therapies (PACT), and Cancer Moonshot.¹ There has been particular success in the field of cancer, with new medications developed for a specific cancer types with certain genetic characteristics. With increased funding, decreased costs to sequence DNA and analyze genetic information, and improved data analytics, many believe precision medicine to be the future of healthcare delivery.

1. Bresnick, Jennifer. 2018. “What Are Precision Medicine and Personalized Medicine?” HealthITAnalytics. HealthITAnalytics. January 11, 2018. https://healthitanalytics.com/features/what-are-precision-medicine-and-personalized-medicine.
2. Genetics Home Reference. n.d. “What Is the Difference between Precision Medicine and Personalized Medicine? What about Pharmacogenomics?” Genetics Home Reference. Accessed October 11, 2019. https://ghr.nlm.nih.gov/primer/precisionmedicine/precisionvspersonalized
3. Council, National Research, Committee on a. Framework For Development a. New Taxonomy of Disease, and Others. 2010. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease. National Academies Press.
4. “FACT SHEET: President Obama’s Precision Medicine Initiative.” 2015. Whitehouse.gov. January 30, 2015. https://obamawhitehouse.archives.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative.
5. “Program Overview – All of Us | National Institutes of Health.” n.d. Accessed October 11, 2019. https://allofus.nih.gov/about/all-us-research-program-overview.

While there may be some debate as to who deserves credit for originally developing insulin in the 1920s, there is no doubt that its serendipitous discovery had a life-saving impact. In an attempt to provide affordable treatment to the public, the researchers opted to sell the patent for insulin to the University of Toronto for $1. The researchers later collaborated with a pharmaceutical company to develop insulin due to limited ability of the university to develop it on its own. Once made primarily from animal sources in limited selection, several insulin options are now available, and each product differs slightly in manufacturing and design to better mimic the lacking endogenous insulin in patients with diabetes. Today, insulin is marketed primarily by three manufacturers, and counterintuitive to its length of time on the market as a primary treatment, insulin costs continue to increase. One assessment reported that annual spending per person with type 1 diabetes nearly doubled between 2012 and 2016, and the reported cost of one specific brand of insulin increased by 668% from 2001 to 2015. There are several purported reasons for the high costs of insulin, even resulting in lawsuits and a push for legislative involvement.

The high cost of insulin is a hurdle for many patients and the entire healthcare system, especially considering a reported 1.2 million Americans have type 1 diabetes and a portion of the nearly 30 million Americans with type 2 diabetes are insulin-dependent. So, what happens when a medication necessary for life continues to increase in price? Patients may resort to acquiring insulin from less expensive resources outside of the United States (US). In addition, some patients will continue to use insulin vials beyond their stable use (i.e., beyond 28 days once opened) or share insulin pens. Patients may ration their insulin for their own use or sell the remaining insulin to others, as the temptation for potential income may be too enticing for those with limited financial means. One study reported that the rise in costs has resulted in nearly 25% of patients not taking insulin as directed. Lack of blood glucose control resulting from these measures could be life-threatening.

Taking insulin access to another level, one project aims to develop a protocol for insulin production that would circumvent intellectual property concerns, enabling manufacturers to produce more affordable insulin. Theoretically, an open protocol for manufacturing of insulin could result in community biolab production or somewhat “home-brewed” insulin, but there would still be several costly regulatory hurdles for each product. Even if crowdfunding could support these “biohacked” insulin barriers, would the resulting product be the best treatment for all patients? Would it still result in a high-cost product?

Historically, the US Food and Drug Administration (FDA) has regulated insulins as small molecule drugs; thus, the few generics available are actually branded competitors and considered “follow-on” insulins. The FDA has announced insulins will be transitioned from the small molecule pathway to the biologics pathway effective in March 2020 as part of their Biosimilars Action Plan. According to acting FDA Commissioner, Dr. Ned Sharpless, after this transition, the FDA will be able to license biosimilar and interchangeable insulin products that may be substituted at the pharmacy, potentially leading to increased access and lower costs for patients.

While the idea for “generic” (cheaper) insulin is becoming more of a reality, what will patients do in the meantime for a disease state in which the treatment is not optional? Will interchangeable biosimilar insulin finally be the solution for reversing the constant upward trajectory of insulin prices?

Magellan understands that the market looks at pharmacy trends as a gauge to measure pharmacy benefits manager (PBM) success. However, you really can’t compare one trend number to another as every PBM uses different methodologies, different data sets and different calculations to arrive at their trend number, and often adjustments are made to these calculations year-over-year. This is something Magellan likes to call little ‘t’ trend.

Do you know what most of these trend numbers are missing? One of the largest cost drivers today – prescriptions drugs dispensed through the medical benefit – when you combine pharmacy benefit with medical benefit spend, you get what we like to call big ‘T’ Trend. In fact, you need to combine both to see that there is as much, if not more specialty spend going through the medical benefit today that is going unmanaged.

As specialty costs continue to soar the need to leverage effective management and thought-leading expertise is essential.  As pioneers in this complex specialty environment, we have dedicated ourselves to solving the challenges and creating solutions that resolve what’s truly driving big ‘T’ Trend.

Watch our video to learn more.

Learn more about ways to keep specialty spend, an important — and quickly growing — area of pharmacy spend, from Matt Ward, Magellan Rx Management’s general manager of the employer segment. Ward’s op-ed on the subject was recently published in WorldatWork’s magazine. WorldatWork is a nonprofit human resources association and compensation authority for professionals and organizations focused on compensation, benefits and total rewards.

Read more here: Six Ways to Keep Specialty Spend Under Control