SPECIALTY CLAIMS AVOIDANCE

Specialty treatments continue to be the fastest growing area of pharmacy spend, with utilization as the main driver

As renewals are creeping up, are you prepared with a Specialty Drug solution for your clients?

Here is the case study from just one of our brokers:

1 Broker
12 Self-Funded groups (3000 lives)
37 Patients
103 Specialty Scripts Dispensed
6 Month SAVINGS
Commissionable and Passive

Here is what the industry is saying about Specialty Medications and its costs:

"CVS's 2020 report states that 52% of the total drug spend is in Specialty"

The growth of Prescription drug benefit cost continues to outpace other medical plan costs, while the average total health benefit cost per employee has been rising by about 3-4% annually in recent years (dipping lower in 2020 due to disruption in utilization). In 2020 Mercer’s National Survey of Employer-Sponsored Health Plans found that large employers experienced growth in prescription drug cost averaging 7%. For those that track specialty drug cost separately reported an average increase of 11.4%, indicating that increased spending on these high-cost drugs is driving the grow of overall drug cost.

(Brown, 2021)

Expect that over the course of the next several years products in the categories of oncology, autoimmune disorders, and diabetes will drive therapeutic growth. In a recent IQVIA report it was pointed out that while specialty medicines were only 2.2% of prescription volume it is projected that by the end of 2020 specialty medications will account for nearly 50% of the nation's drug spending.

(Steiber, 2020)

WHAT'S THE SOLUTION?

PBMs, like CVS, recommend Copay Optimization, Embedded Disease Management and Medical Specialty Management. Mercer suggests a similar approach to controlling specialty costs.

The Important thing to note is that this cost is being generated by less than 3% of the covered population. We offer a fairly simple solution. it works with these small number of patients, which means no disruption for 97% of your population. These programs can be implemented off-renewal cycle and produce almost immediate savings. In addition, eligible patients pay no deductible or Copay and the Plan saves up to 60% off the retail Plan cost.

PRICE INFLATION

Specialty drugs are not only commanding the pharmaceutical market, they are replacing lower-cost therapies. According to a Segal Report, 40% of new products recently launched by drug manufacturers were specialty medications. These drugs are now being pushed at a higher rate than non-specialty drugs, contributing to price inflation.

Specialty drug utilization increased nearly 6% in 2020, whereas non-specialty drug usage remained relatively the same. And there is little recourse for anyone seeking a cheaper alternative to these specialty pharmaceuticals.

There are currently few biosimilar drugs(similar to the name brand drug’s composition, but not identical) that can be used in place of specialty medications-the FDA only approved two in the first half of 2020 and 10 in all of 2019. However, as more biosimilar drugs are approved, drug manufacturers are expected to introduce other countermeasures to maintain their marker share and profits (Griffin, 2021)

INFLUX OF SPECIALTY DRUGS

Specialty medications account for a smaller portion of U.S prescriptions that non-specialty drugs, yet they commanded nearly half of the pharmaceutical market in 2016 (180 billion). And that dominance is likely to remain. Specialty drug spending is projected to experience rapid growth over the next several years, due to pricing increases.

In 2021, experts predict 11.5% increase in specialty drug prices, compared to a 2.8% rise in non-specialty drug prices. these manufacturer price increases are often cited by insurers as reasons for rising insurance premiums.

Furthermore, approximately 66% of the drugs that gained Food and Drug Administration (FDA) approval in 2019 were specialty drugs, pointing to a steady rise in usage. This trend is likely to continue as more specialty drugs enter the market. (Griffin,2021)

Here is a savings example from 3500 life Medical Group

Effective 5-1-21
24 current patients(>1% of the group)
$6 million in total annual drug spend
$1.7 million in annual Specialty Savings
Reducing the total drug spend by 28% in 1 year

POPULAR AVAILABLE SPECIALTY MEDICATIONS

(58 % of all injectables hit the group’s stop loss)

What WE do at the Pharmacy Exchange

The Pharmacy Exchange provides PROVEN and EFFICENT ways to reduce specialty spend. In most cases a savings of 60% off each program is available for specialty medicine. To submit a deidentified quote click on the link below. It does not cost you anything to obtain a quote, If you provide just a few de-identified fields from you or your client’s monthly drug claim file.

Please contact us at info@pharmaex.org for more information

Submit a Script. Get a quote.

Please allow our team 5 to 7 days to find you savings.

Get a Quote Today!

References:

Griffin, Jeff. “Prescription Drug Pricing Trends.” JP Griffin Group | Employee Benefits Broker, 20 Jan. 2021, www.griffinbenefits.com/blog/prescription-drug-pricing-trends-2021.

Brown, Raymond. “Managing Specialty Pharmacy Costs: What To Look For In The Data.” Managing Specialty Pharmacy Costs: What to Look for in the D, 2021, www.mmc.com/insights/publications/2021/may/managing-specialty-pharmacy-costs.html.

Steiber, Dan. “Editor’s Note: Top Trends for 2020 in Specialty Pharmacy.” Pharmacy Times, 15 Feb. 2020, www.pharmacytimes.com/view/editors-note-top-trends-for-2020-in-specialty-pharmacy.