The Edge

In 2018, the FDA approved 3 new, injectable drugs developed to fight migraine headaches. Expensive new drugs are the talk of the industry, with many more making their way through the pipeline. To serve both the plan and the member, clients need experienced clinicians at their side to manage plan exposure while covering appropriate treatment options.

“Our New to Market clinical program supports evidence-based decisions for the plan and its members,” explains Valerie Woerndle, Director of Clinical Operations. As a new drug comes to market, we:

• Add the drug to our New to Market review list.
• Flag the drug for prior authorization (PA) clinical review.
• Develop appropriate clinical criteria around use of the drug.
• Determine where the drug will sit on the formulary.

This process sparked the launch of our Migraine Management Program. “Our study showed the annual cost for migraine treatment with existing drugs was approximately $150 a year,” says Valerie, “while the annual cost of the new medications would be about $6,800.” The team developed clinical criteria around how the new medications should be used. When they started reviewing patient requests for treatment, they found that 75% of the time, patients do not meet the criteria.

“It makes sense to start the patient with a clinically effective, lower-cost drug, which may work quite well,” Valerie says. “Advice from a trained clinical pharmacist vs. a free reign approach can mean substantial savings for the plan, while still taking good care of members.”

“Prior authorization ensures physicians use evidence-based rules and prescribe the most cost-effective medication,” says Valerie. “A lower approval rate is more effective and our 60% PA approval rate is among the best in the industry.” She adds that CastiaRx takes great care to evaluate each PA thoroughly and in a timely manner with an average turnaround time of 36 hours.

Twice a year, many of us set our clocks for daylight saving time or change our smoke detector batteries. In the PBM world, formulary updates are on a similar bi-annual schedule – typically in January and July. So why do we update our formularies twice per year?

With a constant flow of new drug approvals by the FDA – for expanded conditions and new generics coming to market – it’s our job to make sure our formulary reflects the latest industry happenings. Waiting more than 6 months to move a brand to a non-preferred status, due to a new drug, could cost a payer thousands of dollars of potential savings.

Did you know?

• If a new competitor hits the market, the existing brand often lowers its price or increases the rebate – driving additional client savings.
• A new generic can save hundreds of dollars for a single prescription if it’s the first in that class.
• Some new drugs cost a lot more but don’t offer a clinical advantage over existing drugs.
• With rising prices for generics, sometimes a brand drug is more cost-effective.

We want to equip members to make the best choices. When members are negatively impacted by a formulary change, we notify them in advance and give them medication alternatives. And with our digital Member Center, a search of any drug quickly reveals its formulary status. If it’s a non-preferred or excluded drug, alternatives are listed – making this a handy resource for any visit to a doctor.

Managing complex conditions and specialty therapies can be challenging for patients. When faced with a chronic illness, extra time and attention promote peace of mind. It’s helpful to know what to expect and the resources available, and that’s the idea behind our new patient video series.

What does a specialty pharmacy do? How does it help patients get financial support for their medication? Does it help navigate processes with insurance companies? As part of the CastiaRx relationship with Diplomat Specialty, we go beyond the basics for a more personable approach, with 1-3 minute videos that can help patients understand how our specialty pharmacy is part of their care team. Patients are invited to sign up to receive a series of seven videos, one per day, to help them get off to a smooth start on therapy and navigate their health journey.

For clients, this means your members on specialty therapies become more educated and confident, and your staff gets fewer phone calls since common questions have been answered. Take a couple minutes to watch the sample patient video above!

There’s something new in the Member Center – an exciting capability that’s been widely requested and anticipated. Filling a prescription means no more wondering about where that order is in the process, whether a refill has been secured, when it will be shipped and when the member can expect it to arrive.  Enhanced order tracking is here!

Our refills are processed quickly – typically three days or less – but members still appreciate following the progress of their orders. Now, they can check the status of home delivery orders at their convenience, any time, any place. And the best part – it’s easy! The Order Status and History page updates when an order is placed, processing and shipped. Once a refill has shipped, the tracking number is linked to the full shipment details.

We know that member satisfaction is higher when people have online choices for working with their benefits. That’s why we continually enhance our digital Member Center. Additional enhancements for 2019 include:

• Notifications once an order has shipped.
• Online payments for home delivery refill orders.

Last year, we added home delivery features that gave members the ability to order home delivery refills and enroll in auto refill. Of course, everyone can still reach us by phone, but for those who prefer to have immediate access to plan information and other capabilities – the Member Center is invaluable.

Did you catch our article on the Member Center campaign in the May issue of The Edge? In it, we explained how we’re promoting and driving awareness of our digital tools across all plan members. Remember, we can also reach out to your plan members directly. Contact your account manager to get a tailored campaign underway!

When you’re the one responsible for your health plan, choosing a formulary is one of your most important decisions. A formulary is the backbone of your pharmacy benefits – it determines the savings you achieve and the breadth of medication options you give your members.

A CastiaRx Formulary Analysis gives you all the information you need to make the right choice. A Formulary Analysis reviews historical prescription data to project the potential savings and impact on your plan from moving to a closed formulary. Key metrics include annualized projections for:

• Savings by channel – retail, mail, specialty.
• Number of claims and members impacted.
• Rebate savings.
• Top drugs impacted.
• Total savings.

The Formulary Analysis, presented in a one-page, visual snapshot, helps you make an informed decision if you are thinking about moving from an open to a closed formulary. View this sample report and talk with your account manager to request an analysis specific to your plan.