High cost is only one characteristic of specialty drugs that makes managing them so important. They fall under both the pharmacy and medical benefits, they have complicated treatment regimens, and they have fraud, waste and abuse (FWA) potential. Recent research from Prime Therapeutics LLC shows that a specialty drug managed care (SDMC) pharmacist working with a health plan resulted in substantial savings. The study also reveals the importance of having integrated pharmacy and medical benefit data, as well as prior authorization data.
SDMC Pharmacist Is Specialized Position
An SDMC pharmacist is a specialized position that “requires advanced clinical knowledge of drug therapies, as well as deep understanding of pharmacy and medical drug claim interpretation (e.g., dose, waste and frequency),” explains Patrick Gleason, Pharm.D., assistant vice president of health outcomes at Prime.
An SDMC pharmacist employed by Prime worked with the pharmacy department of a Blues plan from August 2018 to July 2019 to review members using specialty drugs, based on integrated medical and pharmacy benefit claims and prior authorization data. The SDMC pharmacist was looking to make sure members’ use was appropriate, to detect any use that was suspicious and to find opportunities for savings. Once opportunities were identified, the SDMC pharmacist intervened with a provider, plan member, pharmacy or plan.