Specialty pharmacy utilization management programs and 30-day supply claims may improve patient outcomes, reduce waste

Studies find prior authorization programs are associated with increased quality of care and cost effectiveness; 30- versus 90- day supply claims reduce specialty medication waste

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Prime Therapeutics LLC

Apr 04, 2013, 09:00 ET

SAN DIEGO, April 4, 2013 /PRNewswire/ -- Prime Therapeutics (Prime), a leading pharmacy benefit manager, will be presenting three new studies at the Academy of Managed Care Pharmacy (AMCP)'s 25^th Annual meeting & Expo in San Diego today. Studies concluded that UM programs may increase the quality of health care for patients taking specialty medications. Furthermore, 30-versus 90-day retail supply claims reduce specialty medication waste.

Effect of PA programs on MS patient outcomes
In the first study, Prime evaluated utilization patterns using integrated medical and pharmacy claims for natalizumab (Tysabri®), a drug FDA approved for Crohn's disease and relapsing forms of multiple sclerosis (MS), among 8.1 million commercially insured members. All members using natalizumab had an MS diagnosis. Natalizumab is generally recommended for patients who have had an inadequate response or are unable to tolerate an alternative MS therapy, due to the risk of developing progressive multifocal leukoencephalopathy, a rare viral disease that damages the brain and is often fatal. Researchers found that during the six-month analysis period, 50.7 percent of natalizumab new initiators did not have a history of having tried analternate MS medication. The percent of members with no alternate MS agent decreased to 39.0 percent and 26.3 percent for 24 and 60 months look back, respectively.

"Health insurers and payers are increasingly using PA programs to help ensure patients receive the safest and most effective treatment," said Patrick Gleason, PharmD, FCCP, BCPS, director of health outcomes at Prime. "This study finds about one in four patients hadn't tried another MS treatment prior to natalizumab. Thissuggests a PA program could be successful in better determining safe and appropriate treatment for patients with MS."

Improved medication use as a result of PA programs
In a similar study, Prime researchers in collaboration with Florida Blue evaluated use of linezolid (Zyvox®), an antibiotic that the Infectious Disease Society of America recommends should not be used as a first-line treatment for most infections, but rather reserved to treat drug-resistant strains of enterococcus, staphylococcus, or streptococcus. Researchers assessed the impact of a linezolid PA program, which could help better ensure appropriate use of the drug, but could cause some patients to forego all treatment.

In the study, 1.2 million members were exposed to the PA and another 1.1 million members were not. The study found that after 30 days of follow up, the average per member overall costs of care were $4,189 lower for members exposed to the PA submitting a Zyvox claim (p=0.020). Members submitting a Zyvox claim not exposed to the PA had a non-significant 2.8 percent lower hospitalization rate (p=0.582), 3.9 percent higher ER visit rate (p=0.467), and on average one additional office visit (p=0.332).

"This study indicates PA programs can help ensure medications are used appropriately, without negatively impacting patient outcomes," said Gleason.

30- versus 90-day supply claims
The third study examined use of immunosuppressant drugs taken to reduce the risk of organ transplant rejection, including cyclosporine (Neoral®, Sandimmune®, Gengraf®) and tacrolimus (Prograf®, Hecoria™). Typically, immunosuppressant treatment requires switching to different treatments. However, when drugs are switched, remaining medication could be wasted.

The analysis of claims from 9 million commercially insured members found that during the six-month analysis period, 5,703 (0.06 percent) members were identified with 48,730 calcineurin claims. Members were then tracked for 365 days to determine if they switched drugs and if waste occurred. Researchers found average days of waste per claim were 44 days wasted among patients receiving a 90-day retail supply, 16 days waste for those receiving a 30-day retail supply, and three days wasted for those receiving a 90-day supply by mail. Although claims associated with waste were rare, when waste was found it was 10 times more likely to be a retail 90-day supply claim then a retail 30-day supply or mail 90-day supply claim (p<0.01).

"Medication waste is a continued concern of ours, especially in regard to specialty drugs requiring frequent drug switches and supplies beyond the traditional 30 days," said Gleason. "Often, treatment will stabilize for patients after one year, so moving to mail order could potentially reduce the chance of waste and may improve adherence."

About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves nearly 20 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing private companies in the nation.

SOURCE Prime Therapeutics LLC