Plan sponsors managing specialty pharmacy

April 9, 2013

Within current specialty plan designs, 35% of employers surveyed are using tiers, coinsurance and copays

As plan sponsors seek to control spending on specialty drugs, they are discovering that passive strategies are no longer an option.

According to the not-for-profit Midwest Business Group on Health (MBGH), more employers consider themselves to have “above average” understanding of the specialty pharmacy space, 49% in 2012, compared to just 22% in 2011. For some, specialty drugs can account for as much as 40% of total pharmacy spend.

Within current specialty plan designs, 35% of employers surveyed are using tiers, coinsurance and copays. Only 21% use specialty tiers with cost sharing, which underscores the need for benefit design innovation, according to MBGH. Case management, drug utilization and cost sharing are the top three priorities for managing specialty pharmacy benefits.

However, employers should also seek a specialty pharmacy that suits their needs.

A whitepaper released by Avella Specialty Pharmacy in March lists 10 evaluation measures.

  • Access to limited distribution drugs-not all pharmacies can manage drugs that require special handling;

  • Medication therapy management-specialty drugs often require pharmacist counsel and education for the patient as well as technology tools such as text reminders;

  • Customer service-support should include 24/7 availability and copay assistance;

  • Accreditation-several agencies have set specific specialty benchmarks;

  • Quality-look for an internal quality assurance department;

  • Waste management-quantity limits and controlled refills are more cost effective for specialty drugs;

  • Data management-IT must be able to capture and report significant data points;

  • Cost containment-competitive pricing includes discounts off industry pricing standards;

  • Internal resources-every core function from billing to formulary management should be built into the specialty pharmacy’s infrastructure; and

  • Community standing-specialty pharmacy should not be an add-on service.

With 1,200 new drugs in the pipeline-many expected to be specialty drugs-sponsors should be prepared for steep trends in the future.