Specialty Drug Management
Specialty drugs continue to represent one of the most significant cost components in your overall drug spend. By definition, these drugs require special handling, are many times administered by infusion or injection, and are high cost. Most PBMs define high cost as $600 or more per month. The average specialty drug therapy is $18,000 per patient per year. Many of the high cost biologics are included in this category.
While today, most specialty treatments are prescribed for relatively rare conditions (multiple sclerosis, rheumatoid arthritis, hemophilia, etc.) and cancer, the next few years will see the treatment of chronic conditions, such as diabetes and heart disease with specialty drugs. Most forecasts call for an expected 45% of drug spend to come from the specialty category by 2020.
A well designed specialty drug strategy is necessary to help mitigate these rising costs. Wilkinson Benefit Consultants will address the use of restricted distribution channels, contracted discounts, specialty inclusion lists, prior-authorization edits, specialty rebates, limited days supply and other review criteria to determine a “best practice” strategy for your plan. Additionally, we will analyze and evaluate the use of a centralized prior authorization control, site of care alternatives, plan design optimization and reimbursement management.
In order to better manage your specialty drug spend, you must first create an accurate baseline of the plan’s total drug cost attributed to specialty pharmacy. This includes those costs being allocated to the pharmacy benefit and those being paid through the medical plan. WBC can review your specialty drug spend that occurs in your medical plan and incorporate it into your pharmacy cost to determine a true PMPM cost for specialty. We do this by creating a cross bridge to convert medical “J” codes into the appropriate National Drug Codes (“NDCs”). This total picture then enables us to analyze and recommend the most effective specialty strategies that will support enhanced patient outcomes and mitigate specialty drug cost trends.