The vital role of pharmacy benefit management in oncology

I began my career as a pharmacist 14 years ago, working in retail pharmacy for a major drugstore chain. I loved it — connecting directly with patients, helping them understand and navigate their prescriptions, and seeing the direct impact of my work, day in and day out.

Now, as director of Specialty Cost of Care for Carelon, I think back fondly on that time and the lessons it taught me about the important role pharmacists play in people’s care. I’ve also had the opportunity to witness the pivotal role that pharmacists play in oncology.

Pharmacists are integral not only behind the counter, but also in shaping broader healthcare strategies — particularly those working in the capacity of pharmacy benefit managers (PBMs). PBMs play a critical, strategic role in working to manage drug benefits and optimize the delivery of pharmacy care. This work ensures that patients receive the best possible outcomes at sustainable costs. The balance is crucial in cancer care, in which drugs are a significant cost driver, representing potential lifesaving treatments for patients.

Oncology is a rapidly evolving field, and cancer drugs are an exploding class, both in terms of the treatment options they represent and the price tags they carry. The need for oversight is critical, not only to control costs but to ensure the provision of evidence-based treatment. An April 2024 Journal of the American Medical Association (JAMA) study  found that less than half of the cancer drugs approved under the FDA's accelerated approval pathway between 2013 and 2017 improve overall survival or quality of life, despite being in the U.S. market for more than five years.

To evaluate clinical effectiveness, our pharmacy and therapeutics committee analyzes clinical trial and safety data to create evidence-based guidance on the most clinically effective drugs. A value assessment committee then marries those clinical decisions with cost considerations. In some cases, generic drugs may be substituted for brand-name options where they are clinically equivalent.

PBMs also use tools such as prior authorization and step therapy to ensure appropriate medication use in cancer care. Prior authorization requires healthcare providers to obtain approval before a specific medication is dispensed, ensuring its appropriateness for the patient’s condition. Step therapy involves starting treatment with cost-effective and proven medications before moving to more expensive or advanced therapies if necessary.

 

The benefit of integrated management

At Carelon, we’re fortunate to be in the unique position of being able to integrate medical and pharmacy benefit management for a truly holistic approach to care. Patient care is most effective when all aspects, including treatments, visits, and medications, are considered together rather than in isolation.

By managing medical and pharmacy benefits together, healthcare providers can more effectively monitor and adjust treatments based on a patient's overall health needs. This can lead to increasingly personalized care plans, better health outcomes, and a more efficient use of resources.

We’ve found that we can manage best as PBMs when we have the full picture of a patient’s journey and needs. This is particularly so in cancer care, as injectable and infusion-based chemotherapy drugs often land on the medical benefit side. Having medical and pharmacy benefit management united under a single umbrella is a boon for the patient, the care team, and the payer.

 

Specialty pharmacy strategies for oncology care

From outreach to disease management, Carelon’s specialty pharmacists have several opportunities to intersect with cancer patients along their care journeys as well as provide assistance and guidance. Outreach programs can alert members or care providers when there’s an opportunity for dose optimization, and tools such as the Clinical Rules Engine (CRE) can flag gaps in care or nonadherence for oncology medications, triggering outreach to the member or care provider.

Innovative waste management tools provide greater flexibility. Our Split-Fill Program limits oral oncology drugs with a high discontinuation rate to a 15-day supply, so if patients need to stop or decrease their dose or change therapies, they’re not burdened with excess medication or wasted copays.

Our Oncology Disease Management Program provides high-touch drug therapy management to members on oral cancer medications. Sometimes, patients will stop taking their medications as advised due to confusion or discomfort with side effects, which can greatly hinder treatment outcomes. Clinical pharmacists provide comprehensive therapy support, including counseling, adherence and side effect management, and access and copay assistance support. The goal of the program is to improve quality of care and reduce drug-related adverse events and avoidable costs.

We’ve seen great success with this program and continue to expand it to include more pharmacists and members. It’s striking to see the impact that a simple phone call from a pharmacist to a member can have.

For instance, a pharmacist with our program reached out to a member who’d recently started taking a cancer medication, to see if he had any questions or concerns. The man mentioned having shortness of breath and difficulty sleeping and said he planned on mentioning it to his care provider at a future appointment. The pharmacist told the member that they’d reach out to his care provider on his behalf. The care provider quickly followed up with the member and adjusted his medication to one that didn’t carry such severe side effects.

In another instance, a pharmacist reached out to a member and discovered that he’d been taking an incorrect dose of his cancer medication. After confirming the correct dose with the care provider, the pharmacist got the clinical staff to reconnect with the member and clarify the dosage and directions. This prevented an adherence issue that could have led to a poor treatment outcome.

These examples speak to the importance of human interactions in the specialty pharmacy space, where clear, compassionate support and resources are paramount. Digital tools are useful in both member outreach and prescription management, but I expect a continued emphasis on human-to-human communication that maximizes clarity and connection. Digital platforms that enhance and support those interactions will continue to be integrated.

 

An optimistic future

Oncology is a particularly exciting space for pharmacists because it’s moving rapidly and visibly in the right direction. We now have treatments that are dramatically affecting the longevity of patients, sometimes even resulting in cures. Immuno-oncology drugs cause far fewer side effects than traditional chemotherapy drugs, and gene therapies are providing tremendous advancements and novel opportunities. Biosimilars, or drugs similar to what's called a reference drug, are increasing competition and options in a space that previously lacked them.

The unfortunate reality is that most people’s lives have been touched by cancer — whether our own, or that of someone we love. To have new, potentially lifesaving drugs emerging is a cause for optimism and celebration. As pharmacists and healthcare professionals, we’re tasked with the critical role of making these innovations accessible and affordable. In this dynamic environment, our commitment remains steadfast: to ensure that the advancements in cancer treatment translate into real-world benefits for all patients, touching lives and offering renewed hope.