Tulpenmanie Mania Golden Triangle Specialty Network, LLC Connor Castleman – Director of Operations Taking complex to simple. www.gtspecnet.com
Taking complex to simple. www.gtspecnet.com
What defines a Specialty Pharmaceutical? Specialty drugs or specialty pharmaceuticals are a recent designation of pharmaceuticals that are classified as high-cost, high complexity and/or high touch. Specialty drugs are often biologics — "drugs derived from living cells" that are injectable or infused. • High cost • Special handling/administration • Complex conditions/patient monitoring Taking complex to simple. www.gtspecnet.com
Medical Benefit not Pharmacy Benefit • Specialty drugs administered by physicians or in a clinical setting will be under Medical Benefit. • Designated with a J-code and Health Care Procedure Coding System (HCPCS) Taking complex to simple. www.gtspecnet.com
Taking complex to simple. www.gtspecnet.com
Common Specialty Conditions • Rheumatoid Arthritis • Cancer • Multiple Sclerosis • Growth Deficiency • Infertility • Pulmonary Arterial Hypertension • Bleeding Disorders Taking complex to simple. www.gtspecnet.com
Taking complex to simple. www.gtspecnet.com
PBM Drug vs Specialty pharmacy Specialty Pharmacy PBM • Entyvio – J3380 • Adempas • Keytruda – J9271 • Exjade • Ocrevus – J2350 • Farydak • Opdivo – J9299 • Gattex • Orencia – J0129 • Gleevec • Remicade – J1745 • Rituxan (Hycela) – J9311 & • Ninlaro J9312 • Otezla • Soliris – J1300 • Sprycel • Spinraza – J2326 • Tasigna • Yervoy – J9228 Taking complex to simple. www.gtspecnet.com
Most Utilized Drugs from GTRx 1. Spinraza 2. Remicade 3. Keytruda 4. Ocrevus 5. Yervoy + Opdivo 6. Entyvio 7. Soliris 8. Rituxan Taking complex to simple. www.gtspecnet.com
How does GTRx work? Send Referral to Opportunity - Yes or GTRx No Out Reach Approval from • Negotiation TPA/Group • Alternative Sourcing • Alternative site of Care Approval from Savings Provider Taking complex to simple. www.gtspecnet.com
Case Studies Case 1 – Empowering Case Management with GTRx A patient was diagnosed with malignant melanoma of right lower limb, including hip, and was prescribed a treatment program including 13 cycles of an antineoplastic immunotherapy of Opdivo. The patient initially went to a local hospital for these outpatient infusions. The hospital initially quoted billed charges of $70,828 per treatment for the patient's dose of Opdivo. After the PPO discount, the paid amounts WOULD have been a staggering $57,774 for a single dose of Opdivo. The GTRx Specialty Pharmacy Network rate was $12,686 per treatment. The provider, however, refused to allow an outside source, such as GTRx, to supply the medication to their hospital for the patient's infusions. Due to their refusal, Hines and GTRx began price negotiations directly with the hospital. With GTRx pricing as leverage, Hines and GTRx negotiated the rate down to $34,000 on the first two treatments for immediate savings and financial relief to the plan. With the patient's willingness to change the site of care, Hines and GTRx further pursued implementing GTRx's preferred sourcing strategy. While searching for other provider options in the surrounding area, Hines found a facility that would administer the Opdivo at a cost of $14,318, resulting in significant savings for the plan on the remaining 11 treatments. Taking complex to simple. www.gtspecnet.com
Case Studies Case 2 – Site of Care Intervention A patient diagnosed with Crohn’s disease was receiving Remicade treatments at the infusion suite of a local hospital. Working closely with the patient and patient’s doctor, Hines Case Management and GTRx presented home infusions as an available option and successfully coordinated a change in site of care. The patient now receives the treatments in the comfort of their own home. The patient and family have been very pleased with the transition and overall convenience of receiving the treatments at home - on their schedule - with a specialized infusion nurse. With preferred drug pricing through GTRx , the patient’s change in site of care saves the plan an average of $9,500 per treatment (Every 6 weeks) Patient Feedback from Hines Case Management “I had a conversation with the patient’s spouse this morning. GTRx is currently providing his Remicade infusions at home since March 2018. They’ve been very impressed and completely pleased with the home infusion. She states it's going wonderfully and has been an incredibly easy process and it was a smooth transition for them. “ Taking complex to simple. www.gtspecnet.com
Case Studies Case 3 – Identification, Implementation of GTRx Preferred Sourcing with a Major Hospital A patient diagnosed with metastatic melanoma received their first dose of Keytruda at a major hospital system. Working in close collaboration with the plan’s administrator, GTRx was able to identify significant potential savings within days of the patient’s first treatment through weekly data analysis of the groups medical spend. The Hospital billed $43,160 for the Keytruda, and the PPO network only provided a 10% discount off of billed charges. Golden Triangle’s rate for the exact same dose of Keytruda was $9,684. With GTRx in place as the plan’s preferred source for specialty drugs, Golden Triangle (in collaboration with case management) was able to restock the hospital’s pharmacy for the patient’s first dose of Keytruda, as well as supply the drug going forward for all future treatments – eliminating the egregious markup and securing a competitive and fair price for the drug. Savings amounted to roughly 30k per treatment (every 3 weeks for 9 cycles) Taking complex to simple. www.gtspecnet.com
Parting thoughts • Involvement of Group and TPA • Case Management • Review your medical spend data Taking complex to simple. www.gtspecnet.com
References 1. UnitedHealth Center for Health Reform & Modernization. Issue Brief: The Growth of Specialty Pharmacy: Current trends and future opportunities. April 2014. 2. Ha T. Tu and Divya R. Samuel, “Limited Options to Manage Specialty Drug Spending,” Center for Studying Health System Change, Research Brief No. 22 (April 2012): 1-13. Taking complex to simple. www.gtspecnet.com
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