Derek van Amerongen, MD, MS: Subcutaneous methotrexate requires a prior authorization. It’s indicted for severe rheumatoid arthritis and should really only be used after the patient has had a meaningful trial of, for example, generic methotrexate. Many plans may cover that through their specialty pharmacy arm, either through their PBM (pharmacy benefits manager) or, if they have that service, bundled within the services of the plan. Usually, because of the complexity of that type of drug, that’s not something that’s going to be available at retail. But certainly accessing it through retail could be an option, depending upon the plan design. Frequently, we have requests for retail of drugs like this come to us, mainly when you’re talking about people who are in geographically isolated areas or if there’s some issue where the specialty pharmacy can’t deliver the product—say, through overnight shipping or something of that nature.
Most health plans will use a limited network of specialty pharmacies to manage not only rheumatoid arthritis but also, really, all chronic conditions involving specialty drugs. The advantage of having a limited network is primarily control. It means that we can validate the quality of service, that we have visibility in terms of who the members are who are on these drugs, as well as the physicians prescribing them. It also allows the health plan to collect those data—ideally, in real time—so we can track the progress of the patient and identify any issues as they evolve. It also is a great data source to allow us to have nurse case managers, disease case managers, and pharmacists who are involved with managing specialty products to reach out to the member and make sure that the member has all of the tools and education that he or she may need.
Access to biologic drugs and, really, all of the drugs available for rheumatoid arthritis is obviously critically important. My experience has been that rheumatologists, because they are so heavily focused on this particular area, are very knowledgeable about how to make the system work efficiently and what they need to do in order to obtain prior authorization approval from the health plans of the patients that they serve.
Many plans, such as ours, have pharmacists who are dedicated—especially in the pharmacy area—and their job is to provide education and touch base with the member in between dosage refills, and make sure that there aren’t any issues around claims or delivery; they also validate that the member understands the proper way to administer the drug and has not had any problems. It’s really meant to complement the education and support that the physician is giving in the office and to make sure that the member has that practical piece, so that he or she will be able to use the drug in the best and most efficient way.
Adherence and compliance are critical for any condition, and they’re certainly very, very important in rheumatoid arthritis. Even though we’re talking about conditions that can have a major impact on lifestyle and an individual’s ability to be mobile and functional, we still see challenges with adherence, even in a situation like this.
One of the things that our plan does—and this is a common scenario across managed care—is that we have pharmacists who are dedicated to the specialty pharmacy area, whose job it is to contact members on a monthly basis prior to us distributing the next dose of the medication to make sure that the member’s doing well: to identify any problems with the last month’s treatment, to find out when the patient has their next visit with the physician, and to answer any questions that the patient might have prior to that next physician visit.
Some of the things that our pharmacists do, which I think are very important in terms of member support and maximizing adherence, are actually some very nitty-gritty processes, like making sure that any claims issues or cost-sharing issues are addressed and taken care of. They also make sure that when we are going to be shipping out a dose of a very expensive drug, the member’s there to receive it, so that we don’t have any challenges with drugs being lost or spoilage along the way. I think that extra service and customer support are really critical in making sure that we’re getting maximum levels of compliance from members.
Rheumatoid arthritis is a complex condition, and there are many issues that need to be addressed for a patient/member who is being treated for rheumatoid arthritis. Many plans, such as ours, will leverage many different individuals and competencies to help support that member. We have, for example, case managers and nurse disease managers who will contact the member once a diagnosis of rheumatoid arthritis is made to answer questions and make sure that individual is plugged into the right system of care, so that issues around logistics and claims and accessing, testing, and receiving the drugs that he or she may need—all of those are answered.
We also use our pharmacists, who are dedicated to the specialty pharmacy area, to work with the member to address issues that might pop up around dosing, administration, and concerns over potential side effects or tolerability issues. And working together with our nurse managers and our pharmacists, our goal is to complement what’s happening in the doctor’s office by answering a lot of those nitty-gritty, day-to-day questions and address issues. We do this in order to maximize the opportunity for the member to get the most benefit out of the drug and also to maximize the compliance with the treatment that the physician has prescribed.
Certainly, working with the rheumatologist as we go through this process is critically important. Rheumatoid arthritis is a lifelong condition. It’s very important. We believe that our members develop relationships with their rheumatologists, that they are getting the answers and information they need from their rheumatologists. Our nurses and pharmacists work with members to answer a lot of their nitty-gritty questions around logistics, claims, and the actual administration of the drug.
We also are very anxious to be able to share that information with the rheumatologist, assuming that we get the permission of the member to do so. And typically, we do. We think that that’s a way to complement the information that the rheumatologist has in the office from his or her observations and work with a member to make sure that the physician really has a 360-degree view of what’s going on. That, I think, is a way not only to maximize things like compliance and adherence but also, ultimately, to maximize the clinical outcome for the member.