Specialty pharmacy utilization management proves effective

SAN FRANCISCO, April 19, 2012 /PRNewswire/ -- Utilization management (UM) programs such as prior authorizations (PAs) can be used to improve safety and efficacy as well as cost-effectiveness for specialty drugs, according to two new studies being presented tomorrow by Prime Therapeutics (Prime), a leading pharmacy benefit manager (PBM), at the Academy of Managed Care Pharmacy (AMCP)'s 24th Annual Meeting & Expo in San Francisco.

PAs require members meet certain criteria before particular drugs are covered under the health plan. Health insurers and payers are increasingly using these programs to prevent prescribing that is improper or suboptimal for a specific health condition.

In one study, Prime examined the impact of a PA for Ampyra®, a treatment to improve walking ability and speed in multiple sclerosis (MS) patients, on utilization, efficacy and cost effectiveness. Researchers found that after five months of member follow-up the PA program improved safety and cost effectiveness, with an average of 2.1 (p < 0.001) fewer claims per member that avoided an estimated $143,010 in costs.

"Improper use of drugs can prove both expensive and potentially dangerous. Through smart UM programs we can provide guidance for members and providers to help ensure members receive the safest, most appropriate treatment," said Patrick Gleason, PharmD, director of clinical outcomes assessment at Prime.

The second study focused on utilization prevalence and total costs of H.P. Acthar® Gel, used for numerous autoimmune, allergic and inflammatory conditions in adults and infantile spasms in young children. Researchers from Prime in collaboration with two of its Blue Plan partners used integrated medical and pharmacy claims data for a UM assessment. Results showed Acthar Gel use is rare but expensive — 30 of 5.5 million patients queried submitted claims averaging $40,497 per member over a six month follow-up. The most common diagnosis associated with Acthar Gel use was multiple sclerosis. Study authors concluded health insurers and payers should consider implementing a UM program to ensure the most appropriate and cost effective Acthar Gel use.

"By combining medical and pharmacy data in this study, we comprehensively assessed the drug safety, effectiveness and total cost of care. In doing this, we found that a UM program could be effective for Acthar Gel use," said Gleason.

In the first study, paid and rejected Ampyra pharmacy claims were analyzed among commercially insured, continuously enrolled patients during the six-month study period within the 807,801 members who were exposed to the PA and the 257,414 members who were not. To receive initial coverage for two months, a patient had to meet safety criteria (i.e., no seizure history and creatinine clearance was greater than 50ml/min) and a baseline timed 25-foot walk was provided. To continue coverage, patients were required to demonstrate improved walking speed. Ampyra paid claims utilization was compared between the PA and non-PA groups to calculate cost avoidance.

In the second study, Acthar Gel pharmacy and medical claims data were identified for 30 patients among the 5.5 million commercially insured members assessed with six-month follow-up for each member. These 30 members had a combined 43 pharmacy and medical Acthar Gel claims at a total paid amount of $1,214,923; of which 76.2 percent were pharmacy benefit costs and 23.8 percent were medical benefit costs.

Prime Therapeutics is a pharmacy benefit management company dedicated to providing innovative, clinically-based, cost-effective pharmacy solutions for clients and members. Providing pharmacy benefit services nationwide to nearly 20 million covered lives, its client base includes Blue Cross and Blue Shield Plans, employer and union groups, and third-party administrators. Headquartered in St. Paul, Minn., Prime Therapeutics is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those Plans. Learn more at www.primetherapeutics.com.

SOURCE Prime Therapeutics