Payer strategies to manage rising specialty drug costs

Payers are implementing utilization management strategies to curb spending on rising specialty drug costs, according to an Oct. 13 panel hosted by the American Journal of Managed Care. 

Panelists at the Academy of Managed Care Pharmacy Nexus 2022 event described how their organizations have reduced spending on specialty drugs by adding manual chart reviews for prior authorization, adding in-house rare disease experts and enrolling members who need specialty drugs in complex case management. 

Brian MacDonald, PharmD, director of clinical strategy for Magellan Rx Management, described how enhanced utilization management programs for specialty drugs can ensure appropriate diagnostic and treatment decision-making through case management and second opinions. 

"What that personalized care team might look like for any given payer — it probably starts first and foremost with nurse outreach and having a nurse case manager reach out to the member and kick off that coordination of care; tapping into the social workers to provide support for the needs of the member and/or their caregivers; pharmacists can help with that medication reconciliation," Dr. MacDonald said.

A partnership between Blue Cross and Blue Shield of Alabama and Magellan Rx Management for utilization management led to $19.2 million in savings from January 2021 to March 2022, Aravind Chodavapu, PharmD, clinical program manager for the payer, said. 

"We found that this program has been beneficial to our customers by ensuring that we're doing all we can to manage their funds appropriately, all while ensuring that members are getting the appropriate access to these high cost therapies," Dr. Chodavapu said during the panel. 

Read the full summary of the panel here.

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