Employers and other plan sponsors need to work closely with specialty pharmacy providers to manage the payers’ financial risk, while ensuring beneficiaries have access to needed therapies.

Analyze Medical, Pharmacy Claims
“I find most employers don’t realize how much they’re paying for specialty drugs because much is hidden in the medical benefit,” says Lisa Gish, RN,MHA, Executive Director, Tri-State Business Group on Health. “Plan sponsors gain a better picture of expenditures by working with their medical providers to analyze medical claims.”

Use the Best Channel
Using the optimal distribution channel is critical. In some cases it may be more cost effective to cover specialty drugs under the pharmacy benefit rather than the medical benefit (see Figure 4).

Shifting medications to the appropriate distribution channel can save payers as much as five to eight percent on their specialty drug spend, according to Pharmaceutical Strategies Group pharmacy benefit consultants.

Create Separate Cost Share Category
“If plan designs don’t define coverage for specialty drugs, they will be covered by default under the plan’s existing retail and mail copayment structure,” says Gish. “Employers should think of specialty drugs as a separate category of coverage.”

Many employers are creating a fourth tier with more equitable cost sharing for specialty drugs. Coinsurance with out-of-pocket maximums for the beneficiary is one model for specialty cost sharing. It asks beneficiaries to pay a fair share for the costly medications, without creating barriers to care.

Put Clinical Guidelines in Place
Plan sponsors should require the use of evidence-based protocols, prior authorization, and step edits for specialty drugs. These tools ensure use of high cost drugs only when they are clinically appropriate and when first- and second-line agents are not effective.

Drug management programs help patients get maximum benefit from specialty agents by adhering to therapy regimens. Programs that limit the quantity of drug dispensed minimize waste.

Set Priorities for Population
A thorough analysis of disease prevalence and specialty drug use in the plan sponsor’s population will help establish priorities for management initiatives.

Consultants, specialty pharmacy providers, PBMs, and health plans can help employers compile and analyze plan-specific data on:

• disease states;
• disease prevalence;
• specialty drug use;
• specialist, emergency room, and hospital visits; and
• related costs.

Plan sponsors also may want to:

• compare percent change over the previous year
• benchmark against regional or industry data to identify their areas of highest cost and risk.