By: John Thornton
February 15, 2022
According to the Pharmaceutical Care Management Association, pharmacy benefit managers provide prescription drug benefits for over 250 million Americans. Of those Americans, many have chronic diseases such as cancer, multiple sclerosis, inflammatory disorders, and blood cell disorders, which require high-cost specialty drugs. Despite the seriousness of their illnesses, many patients take their medicine as prescribed only 50% of the time, based on data from the U.S. Food and Drug Administration. The FDA estimates that their lack of adherence to prescribed drug treatments generates direct and indirect costs of $100-$290 billion for the healthcare system
Still, specialty drug utilization is on the rise and expected to continue growing over the next few years. That is bad news for employee benefit plan sponsors already struggling under the high costs of specialty drugs. To help address their spiraling specialty drug costs, they are turning to enhanced pharmacy benefit managers and pharmacy benefit administrators.
PBM and PBA services are offered by a range of providers including insurance companies, retail pharmacies and independent PBMs. Depending on the provider, they offer benefit plan design and administration, pharmacy claims processing, formulary management and specialty pharmacy services. IBISWorld estimates that there are 379 PBMs in the U.S. generating approximately $458 billion.
To control rising costs, along with clinical management, these providers are assessing many more variables affecting a patients’ compliance and utilization of specialty drugs. These variables, often referred to as social determinants of health, include a patient’s economic stability, education, family and other supports. Additionally, providers are weighing the impact of different sites of care (i.e., in-patient/outpatient hospital, physician’s office, home setting) on costs.
Specialty drug cost management services
To help reduce their drug costs, plan sponsors are turning to new tools such as specialty drug cost management services which enable their members/employees to gain access to alternative forms of funding. The best of these services use an advocacy model that procures alternatives for hundreds of high-cost drugs used to treat chronic conditions. Not only do these services reduce the cost of the drugs to a plan, but they also lower and/or limit the plan’s liability for stop-loss coverage.
On average, plan sponsors and members can achieve a 50% reduction in their specialty drug expense. To ensure adherence to the member’s drug treatment plan, patients are managed by clinical staff (i.e., nurses, pharmacists, pharmacy technicians) with plan sponsors kept apprised of members’ enrollment in alternative funding programs. Service level agreements reflect the service’s customized medication access ensuring that plan members receive the right specialty drugs and on time. Reimbursements typically take seven business days.
Robust online PBA platforms
In addition to specialty drug cost management services, another way plan sponsors are reducing their specialty drug costs are by utilizing advanced PBA services. These end-to-end PBA services are focused on helping plan sponsors better manage high-cost specialty drugs. This is achieved by giving their members access to a national network of retail pharmacies with mail order capabilities. These easy-to-navigate platforms feature visually-engaging dashboards and offer intuitive functional and real-time data accessible online. Robust tools connect plan members to valuable drug and healthcare information via their PCs or mobile devices 24/7. Through these responsive member portals, members can use quick response (QR) codes on select specialty prescription labels to access drug information and videos on demand. They can even receive real-time alerts relating to their prescription refills.
