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The growth in high-cost injectable and infusion therapies for the treatment of chronic illnesses is a significant management issue for pharmacy benefit managers and payers, experts say.
THE GROWTH IN high-cost injectable and infusion therapies for the treatment of chronic illnesses is a significant management issue for pharmacy benefit managers and payers, experts say.
Robert Taketomo, PharmD, MBA, president and CEO of Ventegra, a La Jolla, Calif.-based contracting service organization, agrees. "Specialty pharmaceuticals continue to be a challenge for many payers and could represent a financial time bomb," he says.
According to Dr. Seifert, the specialty pharmacy industry has been undergoing significant change with market consolidation among various providers. "You will continue to see additional consolidation," he says. "There will also be increased use of medical management through restrictive contracting in therapeutic classes where there are more than one or two viable alternatives. In addition, many providers of specialty pharmaceuticals currently have, and will, implement utilization and disease management programs in an effort to better manage costs and quality."
In many cases, benefit designs are being modified to cover injectables, Dr. Taketomo says.
"Common approaches include additional copayment tiers-for example, the Tier 4 or Tier 5-and the application of coinsurance," he says.
Dr. Seifert foresees an increasing trend for plans and in California physician groups at risk to contract with specialty pharmacies "in order to reduce unit costs and improve utilization," he says.