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Specialty pharmaceutical drug coverage


Health plans are looking for a more integrated approach to managing specialty therapies so they can effectively and efficiently manage the quality of care for the member, as well as the cost to the plan sponsor, say industry experts.

"Some of those approaches involve partnering with a specialty pharmacy to create a strategic relationship or owning and operating a specialty pharmacy," according to Duane Barnes, senior vice president, Aetna Pharmacy Management Fulfillment Operations.

Aetna Specialty Pharmacy is Aetna's in-house specialty pharmacy, offering an integrated approach to managing specialty therapies and member care. "Through this relationship with Aetna, Aetna Specialty Pharmacy is able to monitor specialty medication needs by accessing the member's medical and pharmacy claim data and reviewing the medical history, as needed," Barnes explains. "By using this approach, Aetna can provide information to doctors and patients that can help improve health outcomes and increase productivity, while helping to manage healthcare and pharmacy costs."

Meanwhile, "plan sponsors are concerned with evaluating the distribution channel to improve how their members receive specialty therapies," Barnes says. Aetna has more than 58,000 participating retail network pharmacies; in-house mail-order services with two locations; and in-house specialty pharmacy service and care support.

From a delivery and patient satisfaction perspective, relationships between specialty pharmacies and HMOs are positive, says Mark Jolly, vice president, Payor Solutions, OTN Specialty Services, an independent national specialty pharmacy in Frisco, Texas. "It is extremely important for specialty pharmacies to bring services that add value beyond product shipment," he says. "These services can range from drug therapy management, disease management, usable data and overall expanded patient management."


Oncology, hematology, pulmonary arterial hypertension, autoimmune/inflammatory, multiple sclerosis and rheumatoid arthritis are considered to be up-and-coming specialty pharmaceutical classes because "[they] contain the drugs with a significant investment in research and development," Barnes says.

"The growth of specialty pharmaceuticals presents investment opportunities for pharma and biotech companies alike," says Tim R. Garde, a managing partner at The Star Group and head of Star's Pharmaceutical Marketing Group, a pharmaceutical marketing specialist in Philadelphia. "Therapies could be very expensive, and managed care companies need to work with pharmaceutical companies to set appropriate reimbursement levels depending on course of therapy."

-Tracey Walker Commentary is independent of source data

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