AH073 - How Low Cost Alternative Programs Can & Should Work, with Jackie Lolos, PharmD, and Haleh Campbell, PharmD

Transcript

Lightly edited for clarity.‍

[00:28] Justin Venneri: Hello, and thank you for joining us for another episode of the Astonishing Healthcare Podcast. This is Justin Venneri, your host and senior director of communications here at Capital Rx, and I'm excited to be able to chat with two of our pharmacists for today's episode. And this is going to build on our sort of 101-level content and how things actually work in the trenches, so to speak.

So welcome to the show. Jackie Lolos, PharmD, Formulary Operations Manager, and Haleh Campbell, PharmD, who goes by “Halls” here on our team. Halls is a Clinical Care Program Supervisor.

[00:56] Jackie Lolos, PharmD: Thanks so much for having us, Justin.

[00:58] Haleh Campbell, PharmD: Thanks, excited for this discussion.

[01:00] Justin Venneri: Now, before we dive into how low-cost alternative programs work and delivering this sort of care to members, this is the first time on the show for both of you. So again, I really am happy to have you here. Would you mind giving us a quick overview of your backgrounds and how you came to Capital Rx? Jackie, do you wanna go first?

[01:16] Jackie Lolos, PharmD: Sure. Thanks again, Justin, for having us on the podcast. Excited to talk about Rx Smart Save today. So yeah, I'm Jackie Lolos, Formulary Operations Manager here at Capital Rx. I started my pharmacist journey doing a managed care residency post-graduation. I worked at a health plan for about a year, and then I came to Capital Rx about three and a half years ago, where I was a Formulary Programs Pharmacist, and now I'm a Formulary Operations Manager leading Rx Smart Save. And I'll pass it over to Halls.

[01:46] Haleh Campbell, PharmD: Hi, thanks, Jackie. I've been a pharmacist now for about 20 years, and like many pharmacists, I kicked off my career in community pharmacy. After 13 years in retail, I decided to embrace a new challenge and transition into the specialty pharmacy space. I worked as a clinical pharmacist, and in 2021 is when I found my way to Capital Rx, where I started as a Clinical Care Pharmacist. After about a year and a half of growing and learning, I was promoted to Supervisor of Clinical Care, and now in my current role as Clinical Care Program Supervisor – which I absolutely love – my team and I help support the development and implementation of Cap Rx's innovative clinical programs.

[02:34] Justin Venneri: Okay, thank you both for sharing your backgrounds, and now to follow your backgrounds – Rx Smart Save. Jackie, can you give us a rundown of what Rx Smart Save is? Are there different levels? How does it work?

[02:47] Jackie Lolos, PharmD: Yeah, of course. So, Rx Smart Save is one of our clinical programs. It's a cost containment program. As we mentioned before, it's our low-cost alternative program where, basically, if a member fills a high-cost target drug, we recommend alternatives that are clinically equivalent and lower cost for the member and the plan.

And there's two different levels to this program. We have Level 1, which is a more low-touch approach. And this is where members receive messages through their Capital Rx app or web portal showing them how much they could save if they switch to one of the alternatives. Like I mentioned, this one's low-touch. So if the member is interested in switching and saving, it's on the member to switch to that low-cost alternative and call their doctor.

Then we have Level 2, which is a more high-touch approach. And this is where Halls’ team gets involved. But, basically, this is where we have pharmacists and pharmacy technicians making calls to members, doctors, and pharmacies to help members switch to those low-cost alternatives.

[03:47] Justin Venneri: And you both have different paths to Capital Rx, which is interesting. And then this program you work together on, and we've talked a lot about on the podcast, and I'm sure we talk a lot about it with our clients during the sales process and the implementation process, about what types of clinical programs are available and how they work. In this case, cost containment. Where does that fit, Jackie? Along with the other clinical programs we offer, is it its own thing that you kind of add on, or is it part of a package? Like, can you just spend a second on that and how that works?

[04:18] Jackie Lolos, PharmD: Yeah, no, it's its own separate program than the other cost containment programs. And it's fully run here at Capital Rx. We don't use any outside vendors. We manage it from start to finish. We created the technology for the program to work. We create the alternative list that we manage. And like I mentioned, Halls’ team, the clinical care team, they make the outreaches to members.

[04:39] Justin Venneri: Got it. And Halls, I think your team in general, we learned – back when Amy Stockton was on the show – about what the clinical care and support team does in the background for a lot of different programs and for customer care in general. Can you talk a little bit about how your team supports level two?

Related Content

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Signs it is time to change your PBM vendor, and how to overcome common hesitations (Capital Rx / Benefits Pro)

[04:55] Haleh Campbell, PharmD: Yeah, absolutely, Justin. So our wonderful clinical care programs team is a group of both pharmacists and specialists who are really passionate about supporting the Level 2 program, Rx Smart Save. The team manages both incoming and outbound calls. They do a great job of helping members really navigate the world of medications by helping them with knowledge about clinically appropriate, lower-cost alternatives. The team makes daily outreach to members who've recently filled a high-cost medication and reviews alternatives with them. And then they help address general inquiries and check if a member is really interested in making that switch. If a member agrees, then the team will collaborate with the member's prescriber to switch the medication and make outreach to the prescriber through both fax and phone to discuss those alternative options.

And then once a prescriber agrees to switch the medication, our team will then coordinate with the pharmacy to ensure that the new prescription is processed at point of sale. We'll then follow up with a member again to inform them that their low-cost medication is ready for pickup. So our team, really, together with Jackie's team, our main focus is really committed to ensuring that, you know, both safety and effectiveness remain a top priority for our members. Transitioning from these high-cost medications to more affordable options.

[06:15] Justin Venneri: And how do the conversations with, the initial conversation, I mean, how does that usually go, and talk us through just what a member would experience there in that initial conversation?

[06:26] Haleh Campbell, PharmD: So when we reach out to members, our main priority is really to educate the member and let the member know what alternatives we have available and provide education about the therapeutic equivalence that we have. We want the member to know that, you know, they're still able to fill their target medication, but these alternatives are available, and that we will help provide support as far as facilitating that switch if necessary, if they choose to.

[06:53] Justin Venneri: Okay, so it sounds like a pretty generally comfortable, more educational discussion than anything else.

[06:58] Haleh Campbell, PharmD: Absolutely, yes.

[06:59] Jackie Lolos, PharmD: Yeah. I just wanted to add that we reach out to the member first to see if they're interested in switching. We don't reach out to the provider first or the doctor first to see if they could just change the prescription, because we want to make it a more seamless member experience. We don't want the member to randomly get another drug without a notification. So we make sure to inform the member first and then continue the conversations with the prescribers.

[07:22] Justin Venneri: Understood. Probably helps with just streamlining care and making sure everybody's on the same page before something actually changes based on the prescription.

[07:30] Jackie Lolos, PharmD: Right, exactly.

[07:31] Justin Venneri: And then obviously one of the benefits of Rx Smart Save is it offers clients cost reduction, and the member, too. So it's potentially a win-win. Not to be too salesy about it, but can you go into how we actually accomplish this in sort of a seamless way? We're handling all of these, the alerts, the processes, the outreach kind of the scenes to just make it run. Does technology help? Jackie, you alluded to building it into Judi®...

[07:57] Jackie Lolos, PharmD: Yeah. So the way that the program works is we maintain a list of target drugs and alternatives on the back end. We upload that drug list to Judi, and Judi will run test claims. If a member fills a target medication, it runs test claims on the back end for the alternatives that we have listed out. And if those alternatives come back as lower cost for the member and the plan, it will send the message to the members, and it'll basically show the member on the message through the web portal or app how much they could save by switching to those alternatives. It'll give like the co-pay of the target drug and the co-pays of the alternatives, and it'll spell it out for them.  

But like we mentioned and what Halls talked about for Level 2, even if a member doesn't have the Capital Rx app or web portal for Level 2, we call all members, regardless of app registration, and we send letters to all members, regardless of app reg. So, with Level 2 on, there's more of that outreach.

[09:00] Justin Venneri: And Halls, once this all triggers in Judi, and I would think your experience in the retail pharmacy setting and having worked in specialties would help with this outreach you and your team are doing to support the program and the other clinical programs here. But once that triggers in Judi, can you talk a little bit about your direct experience or share a specific example or two of, you know, a highlight here on how this program should work and can work?

[09:27] Haleh Campbell, PharmD: Well, one case that comes to mind we had was for one of our retiree members. This member was prescribed a medication called Zembrace SymTouch, which is an injection that's used to help treat acute migraine headaches in adults. The member's copay was $90 per fill, and we went ahead and were able to reach the member and discuss alternatives. The member had no idea about any other alternatives that were available in this drug class.  

And so once we went over that information with him, he agreed to make the switch. And then further outreach was conducted with his prescriber to facilitate the transition. So after we touched base with the prescriber's office, they consented to the change and submitted the new prescription for Sumatriptan, which is essentially the same active ingredient, but in a tablet form. And so, the member’s new copay for Sumatriptan was $14 per fill after the change.

As a result the member saved about $75 per fill, which led to an estimated annual savings of about $900. So, the member was really grateful for that outreach and the support that they received. You know, what I ultimately really love about this program is that it helps to promote affordable access to clinically appropriate therapeutic equivalent medications that patients and providers may have not previously considered. And it helps ensure that our members, you know, regardless of any financial situation that they might be in, can get the medications that they need. And having that knowledge and access to those lower-cost alternatives will hopefully allow our members to be more adherent to their medication and help improve their overall wellbeing in the long run.

[11:16] Justin Venneri: And I'm curious, the I have two quick follow up questions. So the great story. The provider's office, rightfully protective of their patients and want to make sure that they understand what is being communicated. How does that discussion go when you say, “Hey, we actually were able to get in touch with a member, and you know, there's this low-cost alternative available, they're interested in potentially switching…”? Is it just a very soft-sell sort of discussion, or how does that go?

[11:40] Haleh Campbell, PharmD: It typically is, you know, sometimes we have some providers that don't want to make the switch, aren't comfortable, and then we respect that and we relay that back to the member and let the member know that they can have that conversation with their provider and maybe that's something that they can discuss. But generally, most of our providers appreciate the outreach. A lot of times they don't know what's on the member's formulary and what's, you know, a lower-cost alternative. So we haven't had too many instances where a provider ultimately rejects the request and says, “No, I don't want my patient to switch.” So, we've had mostly positive outcomes from this reaching out to the providers.

[12:16] Justin Venneri: Yeah, that's great to hear. Okay. And I guess that brings up another question, probably more for Jackie. The lists, there are so many approved drugs out there, right. Like it's probably hard for people to be aware of everything that's a potential option. Maybe something new came out, or maybe something went generic - or how does that list aspect of it play in here?

[12:34] Jackie Lolos, PharmD: Yeah, so the list encompasses multiple drugs, and we have certain categories for alternatives that we list out. We have formulation switches. This is for example, let's say a capsule is more expensive than a tablet, we'll have those on the list. We have therapeutic alternatives where it's like a completely different ingredient, where you're switching to another drug, like, for example, Livalo and switching to Simvastatin. They're completely different active ingredients, but they work the same way and are in the same drug class.

And then we also have combination splits. That's where sometimes drugs are more expensive because they have two ingredients. So we recommend splitting them up. We also have generic equivalents where what you mentioned, Justin, if a drug goes generic, we put them on the list, and then we also have another category which is OTC equivalent. If the plan covers OTCs and then OTC comes back less expensive for the member in the plan, it'll also send that back.

So we maintain this list on a quarterly basis, mostly when formulary changes occur. And we put drugs that are on a higher tier as target drugs, and then lower-tier drugs as recommended alternatives. And then we try to stay on top of new drugs that come to market and include those on the list as well with clinically equivalent alternatives.

[13:46] Justin Venneri: And is all of this happening in Judi, in our platform? So is that different for you, Halls, or you, Jackie, coming from your previous experience?

[13:55] Jackie Lolos, PharmD: Yeah, I will say it's definitely easier because it's all in one place. We have the list, we have our member info. All those test claims are running in near real time, so there's no lag there. There are vendors that do something similar, but since it's all in-house, I definitely say it's more unified.

[14:12] Haleh Campbell, PharmD: Absolutely agree. Helps streamline the workflow as well. Having it all in one place and just having real-time access to data is very helpful.

[14:21] Justin Venneri: Okay, and so here we are. Last question for you both. Thanks so much for taking the time today. I'll start with you, Halls, so stick with you. What's the most astonishing thing you've seen that you can share, of course, either during your time at Cap Rx or related to our discussion today from a previous experience in terms of helping with member care, and low-cost alternatives and the like.

[14:40] Haleh Campbell, PharmD: Oh, that's a tough question. There's a lot of great things here at Capital Rx, but I can say I've been a pharmacist now for two decades, and my journey here over the past four and a half years at Capital Rx has been nothing short of transformative really. This has opened my eyes to like remarkable advancements, especially with Judi and all the capabilities it has to offer.

The Judi platform has revolutionized our work with clinical programs. It provides again, real-time access to claims data, helps us quickly identify members on specific target medications and so that helps streamline our workflow, but it also empowers us to help enhance patient outcomes with timely interventions and support. And now that we have Judi Health™, which helps unify both the medical and the pharmacy benefit platforms, along with the new addition of Judi Care, we have become even more member-centric, which is amazing. And so I'm really excited to see what the future has in store for us as we continue to grow.

[15:41] Justin Venneri: Got it. Jackie, same question to you, send us off with a good story.

[15:44] Jackie Lolos, PharmD: Yeah, well, Halls kind of stole my answer too, but I kind of hone in on Judi Health specifically, unifying both medical and pharmacy claims. I think that's a huge game changer for clinical programs, for care coordination, for potential cost savings opportunities. I think having both medical and pharmacy together will really change the industry, and I'm super excited for the future of Capital Rx.

[16:13] Justin Venneri: Okay, thank you both for joining me on the show today and I hope to have you back on in the future to talk about progress with these programs and kind of how it integrates with the unified claims experience.

[16:24] Jackie Lolos, PharmD: Thank you so much for having us, Justin.

[16:26] Justin Venneri: Have a great rest of your day.

‍

‍

‍

‍

‍

If you would like to learn more about Capital Rx’s full-service benefit administration solutions, including our clinical programs, CLICK HERE to get in touch with our team.

‍

Want to stay apprised of the latest Capital Rx news? Sign up for our monthly newsletter!

‍

‍