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Plan sponsors managing specialty pharmacy
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.
A Conversation With Greg Baker, RPh, CEO of AffirmedRx
March 31st 2024Greg Baker, CEO of AffirmedRx, describes his early career, shares some of his critical opinions about the pharmacy benefit management (PBM) industry and how, in his view, his company is offering a better alternative.
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David Calabrese of OptumRx Talks New Role, Market Insulin Prices and Other Topics 'On His Mind'
April 13th 2023In this month’s episode of the "What's On Your Mind podcast," Peter Wehrwein, managing editor of MHE connects with the now Chief Clinical Officer of OptumRx Integrated Pharmacies, David Calabrese. In this conversation, David touches on his transition in January as OptumRx’s former chief pharmacy officer and market president of health plans and PBMs to his new role as Chief Clinical Officer where he now focuses more on things such as specialty pharmacy to home delivery — with an overall goal of creating whole-patient care. Throughout the conversation, Calabrese also touched on the market’s hot topic of insulin prices and behavioral health services within the OptumRx community, among other topics.
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Upended: Can PBM Transparency Succeed?
March 6th 2024Simmering tensions in the pharmacy benefit management (PBM) industry have turned into fault lines. The PBMs challenging the "big three" have formed a trade association. Purchaser coalitions want change. The head of the industry's trade group says inherent marketplace friction has spilled over into political friction.
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Briana Contreras, editor of Managed Healthcare Executive, spoke with Nancy Lurker, CEO and president of EyePoint Pharmaceuticals. Nancy shared a bit about EyePoint and how the organization’s innovative therapies are addressing patient needs through eye care, and most importantly, she addressed C-Suite positions like the CEO role. Nancy shared advice for those seeking to reach the CEO level, especially toward women in healthcare and other roles, and what it takes to run a biopharma company.
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In this second part of a video series, AMCP CEO Susan Cantrell addressed the impact of high prescription drug prices on underserved communities, highlighting disparities in access caused by the pandemic's effects on minority populations. On the industry blame debate, she urged collaborative solutions, mentioning AMCP's engagement with diverse stakeholders to find comprehensive, patient-centric solutions and advocate for policy changes like the MVP Act to address rising costs and access challenges.
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