Managed Care Pharmacist: What exactly did I do?

I like structure and organization (as seen with my numbered and bulleted blog posts with strategic bolding and coloring). I tend to focus on the factual information, which makes complete logical sense with the position that I was in. While I tend to shy away from writing in a free format, I want this to be an “open book” into my past role as the Senior Pharmacist and Residency Program Coordinator on the Clinical Pharmacy Strategies team. I aim to simplify the complex job title and the journey to it.

For additional details beyond my blog post, feel free to click on the link below to listen to a webinar that AMCP provides: “What is managed care pharmacy and what roles do pharmacists play in it?”

https://www.amcp.org/about/managed-care-pharmacy-101/what-managed-care-pharmacy

Back in 2016 (the year I graduated from pharmacy school), the vast majority of recently graduated Doctor of Pharmacy (PharmD) students enter into a community (or retail) role at a local pharmacy [at a Walgreens, CVS, Giant Eagle, etc.] or a clinical position at a hospital [such as Allegheny General Hospital]. From 2010 to 2012, I attended the University of Pittsburgh for my undergraduate studies. From 2012 to 2016, I experienced a whirlwind of emotions at the University of Pittsburgh School of Pharmacy. I never felt like I “fit-in” with what a student was expected to be like. I did well with As and Bs, but my mindset was beyond the GPA. I experienced my first Academy of Managed Care Pharmacy (AMCP) conference in Tampa, Florida in 2014, where it all clicked. These people are like me. To note: I have now attended 14 AMCP conferences in cities across the nation: Tampa, Boston, San Diego, Orlando (2x), Denver, and Baltimore (2x). As a Chair and Previous Chair of the AMCP Membership Committee and AMCP School of Pharmacy Relations Committee and Previous President of the Northeast AMCP Regional Affiliate, I am fully committed to managed care pharmacy, educating our next-generation of pharmacy leaders, and (ultimately) serving the patients in our nation (and even greater across the world).

While I started at UPMC Presbyterian Hospital as a pharmacy intern in 2013, I knew my long-term goal was something “different.” Yes, I love to help ease the worry of confused patients. I love to solve complex drug information questions. I love to use my brain BUT my brain is wired differently. When the interns were focused on treating the patients, I was looking for ways to simplify the workflow, to determine a classification system for inpatient specialty medications, and to convert compounding recipes into electronic formats. Alongside the manager, I attended the monthly Pharmacy & Therapeutics (P&T) meetings to offer input on the medications the hospital should cover. I am business-driven in the healthcare world. I like money (not the aspect of having money in your bank account to convert over to savings). I like knowing how to make money for a business entity and how to save money through process improvements. As a result, I applied for the UPMC Health Plan internship. I needed first-hand experience in the world of “managed care pharmacy.”

According to the Academy of Managed Care Pharmacy (AMCP), “Managed Care Pharmacy is the practice of developing and applying evidence-based medication use strategies that enhance patient and population health outcomes while optimizing health care resources.” Regardless of how difficult it was, I became obsessed with the role. I was provided the opportunity to work as much as I wanted remotely as an intern. A managed care pharmacy setting gave me that adrenaline feeling, where I could sit working on a project for hours at a time without realizing that a minute went by. I truly believe that if you are passionate in your role, you develop this “high” feeling where you are so engraved in your computer screen that not a single person can get in the way. I loved it. I loved the feeling I got when I worked. I could keep working and working. I know it’s dangerous. A danger I stepped into and was sucked into.

Fast forward a few years, I accepted a PGY-1 Managed Care Pharmacy Resident position at Highmark in 2016. The one-year residency program was fast, demanding, and the best experience I could ever ask for. I received feedback for everything that I did from disease state presentations, topic discussions, email communications, and networking skills. I felt the growth almost immediately. The one year prepared me to jump into a Residency Program Coordinator role in 2017.

Being a Senior Pharmacist at Highmark for almost four years, I know one thing. A job doesn’t have to be “just a job.” So what exactly did I do? Who did I interact with? And what is corporate world like? I loved being the Residency Program Coordinator (RPC), since I worked closely with our two residents (on a yearly basis) to manage their day-to-day activities and assist with the residency program design and hiring process. Yes, I worked the typical Monday-Friday with my weekends off. Our arrival time was flexible (anywhere from 7 am to 9 am), but we adjust our exit time to correlate (from 3:45 to 5:45 pm). We can take up to an hour for lunch. The part that I could never give up is the aspect of being the leader of our schedule. I choose how to work and when to work on my tasks. We can send meeting invitations and also decide what days to come into the office versus work from home. I personally crave social interactions and dressing up for a work day (hence my love for fashion as seen through my insta pictures!), so you will see me in the office for the majority of the week 🙂

For one, every day looks completely different. I simply couldn’t provide you with a sample day schedule, since it would not showcase my true workflow. We had our business as usual (BAU) documents, which include preliminary medication reviews, class reviews, and policies. As soon as a drug is approved by the United States Food and Drug Administration (US FDA), my Clinical Pharmacy Strategies (CPS) team researches the drug and writes a preliminary medication review. The review focuses on key information, such as what the drug is approved for, who makes the drug, what the drug can be compared to, how the drug performed in clinical trial(s), how safe the drug is, how expensive the drug is, etc. If a drug is a new molecular entity, we write a full class review (anywhere from 30-80+ pages) that takes an average of 40 hours to complete! To note, a new molecular entity (NME) is a drug that contains an active moiety that has never been approved by the FDA or marketed in the US. We delivered these clinical documents to clients, so we have tight turnaround times that MUST be met. I also served as a peer-reviewer, so I reviewed my team members’ work and propose updates via tracked changes. A policy can be multiple things: prior authorization (PA), quantity limit (QL), or step therapy (ST).

“Prior authorization (PA) is any process by which physicians and other health care providers must obtain advance approval from a health plan before a specific procedure, service, device, supply or medication is delivered to the patient to qualify for payment coverage.” In my role, we focus on PAs for drugs. We write specific criteria to ensure that the right drug goes to the right patient at the right time. The PA can include step therapy (ST), such as stepping through a low-cost, equally efficacious generic drug before trying the brand drug. We add quantity limits (QLs) on drugs to prevent overuse/stockpiling, ensure patient safety, and control healthcare costs. QLs are set by insurance plans in various ways, such as a certain quantity per dispensing event or per duration (like 30 days).

In addition to writing reviews and policies, I met with pharmaceutical companies (aka manufacturers aka “Pharma“). I tend to interact with the Medical Science Liaison (MSL), who presents drug information to my team. My team is split up by disease state. I am a subject matter expert (SME) in Immunology, Dermatology, and Gastroenterology. I also lead our Chronic Inflammatory Disease (CID) initiatives, which includes the following disease states: plaque psoriasis, rheumatoid arthritis, Crohn’s disease, ulcerative colitis, etc. CID is always in the top 3 for specialty drug spend. You most likely have have seen commercials for these CID drugs: Humira, Xeljanz, Otezla, Tremfya, etc. In other words, they are VERY expensive but highly effective.

We have to keep a close eye on how we manage these medications, so we also worked with our Allegheny Health Network (AHN) providers to make sure that our policies align with the best prescribing practices (aka what is actually happening in the real-world). We get the best of all worlds. We reviewed difficult studies, networked with Pharma and doctors, and presented our key findings to our Pharmacy & Therapeutic (P&T) meetings. We then determine where drugs fall on the formulary (Tier 1-5), what utilization management (UM) strategies the drug will have (PA, QL, ST), and how the drug will pay when the patient picks up the drug at their local pharmacy or receives the drug via mail from their mail order pharmacy or specialty pharmacy.

We touch millions of lives with the things we write and the decisions we make. The power is great, so error is not an option. We have to be careful. We have to be strategic. We help each other out (through the peer-review) to leave NO room for error. We may be perfectionists, but we strive to do and be the best for our patients. As our CEO (David Holmberg) says, “Everyday I ask myself, how can I be better than the day before.”

Disclaimer: My corporate job included a vast number of other tasks not detailed above, but I focused on the key items that were more-so consistent in the role. I could write an entire book on what a managed care pharmacist and resident do at Highmark, so I understand that you may have additional questions! Feel free to email me with any comments/questions at Janetta.Geronian@gmail.com 🙂