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

Magellan Rx has been a market leader in developing forward-thinking solutions to combat rising specialty spend on the medical benefit for nearly 20 years. With a passion for solving complex pharmacy challenges, such as biosimilar management, we roll up our sleeves and tackle what is truly driving trend while ensuring a high quality of care for the members we serve.

Building on the success of our industry-first medical pharmacy program, including management of medical benefit oncology drug spend, we began to focus on advancing biosimilar utilization in 2015. Our goal was to empower health plan customers with education and strategies that turned biosimilar availability into cost savings while maintaining clinical quality. From the high-cost autoimmune category to oncology and beyond, our philosophy to biosimilar management involves three key components:

• Proactive Management: Assessing and developing clinical protocols while educating and communicating with network providers
• Medical Pharmacy Execution: Leveraging Magellan Rx’s innovative medical management expertise by incorporating biosimilars into key utilization management programs such as medical prior authorization and provider reimbursement/fee schedule management
• Expert Opinion: Continuously working to gain insights from our advisory board of specialists and Expert Clinical Network of key opinion leaders

But first, what is a biosimilar?

According to the U.S. Food and Drug Administration (FDA), a biosimilar is a drug type that is highly similar to an FDA-approved biologic, or reference product, with regards to its purity, molecular structure, and bioactivity. The biosimilar approval pathway starts with an application submission that includes analytical studies, animal studies, and at least one clinical study. A biosimilar is approved by the FDA after evaluation and testing to show it is as safe and effective as its reference product.

As of April 2021, there are now 29 FDA-approved biosimilar products across three different categories—20 have been launched to date, and 18 are oncology or oncology support.

Magellan Rx’s approach

In 2015, ahead of the first biosimilar approval in the U.S., our work began with a committee of experts to review the biosimilar landscape and potential impacts for payers. By 2016, we had established our first biosimilar-over-reference policy on the medical benefit, and in 2017 additional clients opted into the strategy with more growth in biosimilar savings.

The program was expanded in 2018 to include infliximab—the biosimilar for Remicade, a top spend drug used to treat autoimmune conditions such as rheumatoid arthritis and inflammatory bowel disease—by leveraging a comprehensive utilization management solution. As part of this initiative, our team of highly-trained pharmacists worked with physician offices and hospitals to ensure appropriate utilization for each patient’s unique situation.

Also in 2018, we established an Oncology Biosimilar Workgroup to prepare for future launches in this high-spend category (in fact, oncology and oncology support accounts for more than 40% of total medical pharmacy spend across the Commercial, Medicare, and Medicaid lines of business¹). We aimed to educate health plan customers, members, and providers through individualized strategies that consider clinical, financial, and regulatory factors. The oncology biosimilar program was launched in 2019 as oncology biosimilars hit the market, with early adopter implementation that resulted in maintaining or expanding member access to clinically-effective treatments while delivering significant drug spend savings.

Due to the success of the infliximab program and proactive approach to the launch of oncology biosimilars, we experienced a rapid expansion in 2020 as clients, representing millions of lives, began to adopt these innovative solutions. Oncology biosimilar utilization surged, and the (measured by the number of prior authorizations approved for the first two therapies with biosimilars compared to the reference brands) for early adopters. We also showcased results in research presented at the 2020 AMCP Annual and AMCP NEXUS industry events.

So far in 2021, biosimilar uptake continues to increase. Our team of experts previewed results from the oncology biosimilar program at the 2021 AMCP Annual event and spoke to The Center for Biosimilars on strategies that payers are using to promote biosimilar adoption.

Looking ahead, Magellan Rx remains committed to the biosimilar-first strategy and will continue to expand the program to include additional categories and available biosimilar agents as they are approved by the FDA. For more on payer management concerns related to biosimilars, read page 24 of the latest Magellan Rx Management Trend Report.  For up-to-date pipeline news, check out the MRx Pipeline Report. Have questions or want to implement a solution to meet the needs of your unique population? Connect with us today!

To learn more about Magellan Rx’s work, click here. 

1. Magellan Rx Management Medical Pharmacy Trend Report™, © 2021.

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.

Follow your body’s hunger and fullness signals. Smart snacking can help you keep your blood sugar levels stable, especially if you are taking medicine for diabetes.

Try these tips:

• Enjoy eating the right portion. Try using a smaller plate, bowl, or glass while you slowly eat your snack.
• Make healthy choices. Eat a piece of fresh fruit. Or combine that fruit with some protein, such as a small apple and a tablespoon of peanut butter. Or try dipping your fruit in some light yogurt.
• Be prepared. Keep cut-up raw vegetables in your refrigerator. If these are ready to eat, you’re more likely to grab them than something else. Try a low-fat dip on the side.
• Eat nuts. Try a small handful of almonds, walnuts, or pecans. These treats each have less than 15 grams of carbohydrate.
• Choose filling foods that can satisfy your hunger without a lot of calories. Try a hard-boiled egg or an ounce of reduced-fat cheese, such as string cheese.
• Skip high-fat dips. Instead, mix plain yogurt, fat-free mayonnaise, cottage cheese, or fat-free sour cream with a small amount of dry soup mix. Or try a bean dip made with fat-free refried beans, topped with salsa.
• Get more fiber. Put that turkey sandwich on whole wheat bread. Mix wheat germ into yogurt or sprinkle it on salads. Choose whole-grain breads and cereals.
• Try something new. Make a pita pizza with a piece of whole wheat pita bread, tomato sauce, and a sprinkling of reduced-fat cheese. Top with sliced zucchini or mushrooms. Bake until cheese is melted. Enjoy!

And remember:

• Don’t eat out of the bag or box. Take a single serving, and eat from a plate or bowl. It’s easy to eat more than you need or want when the bag is open in front of you.
• Don’t buy snacks that aren’t healthy choices. If unhealthy snacks aren’t around, you won’t eat them.
• Keep an eye on the nutrition facts label, especially in low-fat or fat-free foods. To make up for flavor, sugar and salt is often added when fat is taken out.

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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Read the full article here:  https://www.healthwise.net/magellanhealth/Content/StdDocument.aspx?DOCHWID=av2453

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.

Magellan Rx Management hosted the 15^th annual Specialty Summit on August 21-23 in New York City with a day-and-a-half of sessions on the industry’s most complex pharmacy challenges and a focus on breakthrough treatments like CAR-T and gene therapy.

A highlight for the audience of 500 was a session on CAR-T, an immunotherapy that is pushing the boundaries of cancer treatment in both children and adults. Dr. Bruce Levine, Professor in Cancer Gene Therapy at the University of Pennsylvania, is a pioneer in this field and presented successful results from the first pediatric patient treated with engineered T-cell therapy—including a surprise appearance from that patient.  Now 13-years-old, she walked across the stage with her parents and shared her dream of being a movie director when she grows up!

Dr. Andrew Scharenberg of Casebia Therapeutics talked through the complexity of gene therapies, including the incredible CRISPR/Cas9 molecular surgery technique that modifies the patient’s own genome to restore ‘normal’ function and, essentially, cure the disease. Colleagues Dr. Jeffrey Trent of TGen and Dr. Joseph Mikhael of TGen and the International Myeloma Foundation shared the stage to discuss mind-blowing advances in personalized medicine that are transforming the lives of children with rare, previously undiagnosed diseases.

Diving deeper into specific categories, Dr. Saira Jan of Horizon BCBS of New Jersey highlighted opportunities to improve quality of care, lower the total cost of care, and enhance member experience through an integrated model of managing autoimmune therapies. Michelle Rice from the Hemophilia Foundation discussed similar strategies for hemophilia treatment, including how advocacy groups, providers, and payers can work together to deliver more effective care.

Several lively panel discussions with industry experts from Amgen, SelectHealth, Mercer, IQVIA, AmerisourceBergen, Pfizer, Barclays, BCBS of Tennessee, Medica, Health New England and Security Health unpacked industry challenges and the continuing evolution of care delivery. Sessions focused on value-based partnerships, overcoming specialty barriers in Medicaid and managing medical pharmacy trend, as well as the impacts and lessons learned from the introduction of biosimilars; through expert insights and real-word examples, attendees walked away with action-oriented solutions for better management strategies and patient care.

Two standout speakers were Mark Johnston of Amazon Web Services (AWS) who reviewed the culture, philosophy, and vision that is driving Amazon’s incredible pace of innovation and how AWS is helping to reshape the foundation of the healthcare industry. An inspiring keynote by Dr. Victor Strecher gave the audience a crash-course on honing your individual life purpose to motivate you through your work, personal ambitions, and family/community goals.

At Magellan Rx, we are passionate about connecting our clients and industry partners to the people, tools, and information needed to make the best decisions for the populations they serve. Our purpose is to help people live more healthy, vibrant lives and take better control of their health. As pioneers in specialty pharmacy management, we are proud of this heritage and develop the Specialty Summit agenda each year with those values in mind. Mark your calendars and join us next year in NYC on August 26-28, 2019 as we host another exciting event packed with timely insights and emerging trends in the evolving specialty market.

When Magellan Health received word that it had been named a Fortune 500 company for the first time in our company’s history, it was cause not only for great celebration, but also reflection.

In recent years, we’ve experienced tremendous growth and momentum. Our purpose—“Leading humanity to healthy, vibrant lives”—fuels the work of our more than 10,000 associates, who are dedicated each day to making a meaningful difference in members’ health and their lives. One of our biggest growth drivers has been our ability to innovate and introduce new products that resonate and disrupt the industry across all areas of healthcare and pharmaceutical management, with the ultimate goal of delivering a consumer-centric model that improves health and health outcomes.

At Magellan, our model of care is unique in that it is both high-touch and high-tech, supported by an innovative and inclusive culture. Three keys to our success stand out.

When it comes to innovation, Magellan’s secret sauce is its culture. We continually seek people from outside the healthcare industry to challenge the status quo and help drive innovation around access to care and care quality with their unique perspectives. By providing our associates the space, flexibility and resources to experiment, we encourage creativity and offer the freedom to pursue ideas that push traditional boundaries. We put a great deal of trust in our talented colleagues instead of relying on a structure that in and of itself is defeatist for innovation.

We innovate with the member in mind. At Magellan, we’re dedicated to consumer-centric care that achieves improved outcomes by integrating healthcare across physical, behavioral and pharmaceutical services. By pioneering new strategies, we’ve been able to tackle the highest-trend components of healthcare expenditures using agile, clinically based technology and applying advanced analytics to develop next-generation solutions. This approach not only enables highly personalized services to be delivered, but also supports the best possible outcomes in the most cost-effective way for our members.

For example, roughly half of total pharmacy spend is driven by specialty drugs, with half of that specialty spend covered under medical benefits. This portion of specialty spend is typically unmanaged by pharmacy benefit managers and health plans. Magellan has differentiated itself in the specialty drug management space by pioneering innovative strategies focused on improved outcomes and value. We provide high-touch decision support tools that support specialty physicians in ordering complicated drug regimens. These tools help to ensure treatments are being administered at the most clinically appropriate site of service and are appropriately used.

We pursue atypical collaborations. Transforming healthcare requires unique collaborations to fuel new solutions that achieve disruptive change and improve health. A majority of our unique collaborations are in the digital therapeutics space. Two years ago, we partnered with Click Therapeutics to create FDA-approved therapeutic apps for treating common behavioral health conditions such as insomnia, anxiety and depression. One example is an app called ComfortAble^TM, which helps people suffering from chronic pain identify and change unhelpful thinking and behavior and learn new problem-solving techniques. At a time when our nation faces an opioid epidemic, much of which stems from difficulties in managing pain, ComfortAble^TM presents an opportunity to curb the use of pharmaceuticals in pain management.

An Eye Toward Tomorrow’s Healthcare Model

As Magellan has migrated to a culture of innovation, one of our biggest learnings is the need to innovate with a small “i.” We’ve learned over time that the best ideas aren’t always going to be big, bold-stroke, billion-dollar ideas. Ultimately, we’re innovating to help people live better, healthier and more vibrant lives. That’s a purpose all of our associates, from our senior leaders to our interns, not only embrace, but act upon.

At Magellan, all of our initiatives are centered on one objective: to provide highly personalized services that support the best possible outcomes in the most cost-effective way for our members. We will continue to innovate and introduce products that resonate, disrupt the industry and make a meaningful difference in people’s lives.

As we look back on 2017, it was a year of many milestones on the United States (U.S.) drug approvals front. With 46 novel drugs receiving Food and Drug Administration (FDA) approval, it reached a 21-year high and more than doubled novel drug approvals in 2016. This count does not even include a number of biologics, vaccines, cell-based therapies, and the first ever, direct gene therapy for a hereditary disease.

Among the historic clinical highlights of 2017 was the landmark approval of two CAR-T therapies, tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™), for select types of leukemia and lymphomas, respectively. CAR-T or chimeric antigen receptor-T (CAR-T cell), is a multiplex process where a patient’s T cells are harvested, genetically modified, and infused back into the same patient to fight cancer cells. 

The role of specialty pharmacies in the invoicing construct for these costly CAR-T therapies is a fascinating component of these new treatment modalities. As illustrated in the CAR-T Invoicing Flowchart, the product is shipped directly from the manufacturing facilities to the certified hospital or treatment facilities. Once the certified hospitals take ownership of the product, they bill the payers who, in turn, pay the certified hospitals. The specialty pharmacies serve as the billing wholesaler between the manufacturers and the certified hospitals to invoice the hospitals and, ultimately, deliver payment to manufacturers. In this unique model, the specialty pharmacy does not handle the drug; rather, it serves as the invoicing clearinghouse between manufacturers and certified hospitals. Hence, there is no interaction between the specialty pharmacy and payers.

Specialty pharmacies are at the epicenter of care for patients with complex conditions. As a high-touch resource, they operate in a clinical environment that leverages specialty pharmacies’ services to dispense, distribute, provide monitoring, case management, adherence programs, reimbursement, and a number of other services particularly for patients with complex and rare diseases. In the CAR-T invoicing construct, the specialty pharmacy takes on the exclusive role of shepherding the invoice.

As we look ahead, future complex therapies will present a new paradigm for all stakeholders including prescribers, pharmacies, payers, patients, hospitals, and regulators. Specialty pharmacies, as an invoicing liaison, may be yet another facet in the evolution towards the next frontier – Specialty Pharmacy 2.0.

“We are often asked in interviews what our most memorable experience has been as a pharmacist,” said Marc. “I used to have a go-to story I thought was amazing, but now that story has been replaced.”
Marc Ream
Clinical Pharmacist, Magellan Rx

This month, we’re celebrating our amazing pharmacists and the work they do to impact members at virtually every point along the patient-care continuum. Today we’re sharing a story from clinical pharmacist Marc Ream, who partnered with the commercial pharmacy team to go above and beyond the call of duty for a family in need.

Although he did not know it then, when Marc Ream took a call late on a Friday afternoon, he was about to experience what would become the most rewarding moment in his career as a pharmacist.

The call came from a mother with an urgent request for an oncology drug approval for her 10-year-old daughter, Jane.* Jane, who lives with Leukemia, needed a specific medication that is relatively rare and not easily accessible. The family was leaving on their long-awaited vacation the next day, so they needed the medication that same day. Marc quickly realized that  getting this medication to the member quickly would require collaboration with the prescribing oncologist, as well as with multiple parties including the health plan, account managers, technicians, pharmacists, physicians and the dispensing pharmacy.

Marc quickly went to work, placing a call to the prescribing oncologist to gather a comprehensive history on the young girl, as well as the necessary clinical rationale to make the approval. Typically, once a medication is clinically approved, the pharmacist’s job is complete and the prescription can be filled by a local pharmacy. However, this particular oncology drug was classified as a limited-distribution medication, typically dispensed only through mail-order facilities. Realizing that the family would not have time to wait, Marc contacted a specialty pharmacy in the area to try to come up with a quicker solution.

He reached out to the pharmacy’s lead oncology pharmacist and confirmed that the medication was in stock, and they conferenced in Jane’s physician to place the order.  Marc worked with the oncology pharmacist to schedule delivery of the medication to the family. When they called the mother to tell her the good news, they could hear the emotion and gratitude in her voice. Thanks to the swift and diligent work of many, Jane and her family were off on their dream vacation with this important medication in hand.

Thank you to Marc Ream and the commercial pharmacy team for this empowering story that shows just how passionate and committed we are to leading humanity to healthy, more vibrant lives.

*Details around the specific circumstances of this story have been changed to protect the identities of both Jane (not her real name) and her family.