2019 Specialty Rx Forum Meeting Summary

PBMI hosted the 3rd Regional Specialty Rx Forum in Minneapolis on September 10th.  The meeting brought together over 100 healthcare stakeholders to join in a dynamic discussion of specialty pharmacy. The following summarizes the event.

Dr. Susan Trieu from MedImpact opened the event with a thought-provoking presentation on next generation therapy. There are more than 7,000 specialty drugs in the development pipeline. When considering the pipeline, we must look at three components: population, market share, and cost. We must also look to the future – for example could CAR T-cell therapies be managed under the pharmacy benefit 20 years from now? Below is an outlook of the future of gene therapies:

  • Research investment will continue but the ability to produce a marketed gene therapy product may limit this investment in the future. If gene therapy does not make it in the U.S., there is fear that there will be a decrease in development.
  • Competition for small patient population
  • CAR T cell therapies potential in the solid tumor market
  • Other therapies that may be significant are gene editing therapies: CRISPR, Zinc Finger Nucleases, TALENs
Interview by First Report Managed Care (FRMC)


We were excited to bring together four perspectives to address the management of hemophilia. Consider that in the early 1960’s the average life expectancy of a person diagnosed with hemophilia was just 21 years. Today, however they can expect to live a normal life span.

James Paist, Executive Director for the Hemophilia Foundation of Minnesota and the Dakotas shared how they work very closely with hemophilia centers, childrens’ hospital programs and clinics to help patients with hemophilia. They provide a variety of programs from financial assistance, educational classes, and kids camps to promote better health. The programs and services they provide help to meet the needs of the community.

Skye Jennifer Peltier, certified Physician Assistant at Children’s Minnesota Hematology Oncology gave an overview of this rare disease and how it has evolved over the years. More factor products are being added each year. Gene therapy is advancing, in 2019 there are 14 Factor products to choose from for those with Hemophilia A and seven for those with Hemophilia B. Over the next four years, four more factor products will be added. Healthcare treatment centers provide a wide range of care and access to several providers (including a PCP, hematologist, physical therapist, dentist, social worker, pain management specialist, and more).

Anastasia Abramson, PharmD, AllianceRx Walgreens Prime, provided us with the pharmacist perspective. When patients receive care, costs are decreased and 40% of patients are less likely to be admitted to the hospital for an episode. Patients infusing three times a week can be burdensome and adherence can become an issue due to the cost. Patients do not check in with their prescriber and will try to make their Factor product last. Pharmacists have an important role in the care and education of patients. In addition to reviewing orders for accuracy, determining appropriate dosing, and providing counseling, they also help patients connect with treatment centers as most do not know they exist. A hemophilia task force through AllianceRx Walgreens Prime reviews variances in dispensing. Utilizing a proprietary program, they can establish a clinical background and an annual bleed rate which helps to identify risk and can escalate to providers where necessary. Dr. Abramson also emphasized the need for policies to allow quick approval of drugs for patients who need their medications and that the criteria for approvals should be flexible.

Donald Glascock provided us with a patient perspective. This was his 50th year living with this condition. Until 1969, there wasn’t much that could be done to manage this disease. He shared the challenges of clotting and how many times it can be a “trial and see situation.” For example, when Factor 8 is administered, depending upon the patient, the body’s immune system might not recognize the Factor and instead try to kill it. Over the years many improvements have been made and with access to social workers, physical therapists, and products, managing the disease has improved significantly. 


The morning’s presentations continued with experts from EnvisionPharmacies’, Kelly Britt and MedTrak’s Marly Arbuckle It takes about 10-15 years to bring a new drug to market at a $3BN cost. Fifty-four billion dollars can be saved by using biosimilars. But with a 50% specialty drug spend, how can we make the use of biosimilars more viable? Just one patient alone can put an employer at risk due to a catastrophic event. As of August 2019, there are 24 biosimilars available, but only 10 have been released to the market and adoption is slow. Advancements in regulatory pathways and key patent expirations is making way for future biosimilars as well as many specialty generics. Patients may have several questions that may hinder adoption of these medications. Engaging the patient is the best tool in the toolkit to change behavior. Prescribers are not opposed to biosimilars, in fact, they have expressed “help us get there, walk us through the process.” Information needs to be disseminated to providers in a digestible format. Sometimes pharmacists have to engage with the physician to help them write for a specialty generic because they are accustomed to writing for the brand. Through proactive and innovative programs around biosimilars and specialty generics, plans can stay ahead of the curve.  One plan recognized an additional 35% in savings with a biosimilar program that included a review of efficacy of new biosimilars coming to market, member communications, and prescriber in-services. An example was also shared for a Plan with a 20% specialty co-insurance under the specialty generic program, that it would be less expensive for the Plan to cover 100% of the generic than 80% of the brand. It’s an all hands on deck approach and we all can help.


Next we heard from Milliman’s Greg Callahan and Brian Anderson who helped us understand some specialty tactics and pricing strategies to help maximize getting the most out of specialty contracts.  It’s important to have language in your contract that addresses when/how/why your specialty drug list will change and when/how you will be notified. This is important because it will impact pricing reconciliation. Definitions matter and can be complex especially since PBMs have different definitions. The speakers emphasized the importance of understanding where the PBM is coming from. Good definitions in a contract are honorable. Therefore, clients should ask two questions: 1) Can you explain them so that I can explain them? Definitions should be clearly understood by both the PBM and the client, and 2) Can the definition be audited? Separate out what specialty performance guarantees are most meaningful to your plan. Allocate risk dollars to these guarantees and ensure your contract language allows for annual review of what performance guarantees pose a financial risk. Keep the contract simple and keep it transparent. We all need to get together and collaborate to move in the right direction to make our clients happy. Figure out what is best for the plan. Conduct a detailed claims analysis. Clients appreciate detail.

Interview by First Report Managed Care


Over lunch we heard from three plan sponsors (The Boeing Company, BCBS of Michigan and Nissan of North America Group) on their successes and challenges with managing specialty. Affordability, sustainability of the cost of specialty drugs, eliminating waste, and maintaining adherence were among the top challenges referenced. They shared that there is a lack of innovation to control costs and that an effort must be made to build trust because the perception is that the health plan is just in it for the money. Access, variability and quality, and lack of advances in technology were noted as the biggest gaps. Three quarters of treatment regimens are suboptimal. There is a huge opportunity to leverage data to get high quality doctors. We need to think holistically. There is a lot of potential to invest in innovation, but it is too early to tell. There needs to be an aligned community of payers and PBMs. Among the successes mentioned in managing their specialty pharmacy were the flexibility to exclude drugs from their formulary, use of copay accumulator programs, and institution of a mandatory site of care. There is so much opportunity across all the channels.

The afternoon kicked off with a presentation from Prime Therapeutics’ Rae McMahan. The pipeline of new drugs will continue to drive up costs for employees, plans and employer groups. Out of the 59 new drugs approved by the FDA in 2018, eight of these drugs drove 1.4% of trend. There needs to be alignment and consistent management. Rae outlined total drug management solutions that crosses three areas:1) under the pharmacy benefit –opportunities to implement split fills (can help save money on expensive oncology drugs); manage use of manufacturer coupons; move to a dedicated specialty network. 2)under the medical benefit – optimize the “right place” to receive medication administration through appropriate site of care; efficient and effective reimbursement; development of medical claim edits; health plan input on preferred medical drug product opportunities to derive net cost savings. And finally, the importance of integrated medical and pharmacy reporting. 

Chris Creamer of Walgreen Co. shared how a community pharmacy coordinates specialty care to patients. They help both the patient and the physician navigate the benefit plan based on coverage. With access to limited distribution drugs, patients can get on their medication therapies quicker. Patients interact with their pharmacist and receive one-on-one consultation and receive personalized care. Patients benefit from local high-touch care, increased patient access and choice, and improved patient outcomes.

We then heard from two PBMs that discussed the impacts of using technology to improve adherence and patient care. Both organizations demonstrated mobile technology/data device solutions. The technology has received positive feedback among patients on these devices

WellDyneRx’s Patty Taddei-Allen, PharmD and Relay Network’s Dan Sweeney emphasized what can be done to help proactively deliver information. Any communication starts around how consumers engage. Utilizing mobile technology, patients can get the right message at the right time. The technology helps to engage patients digitally through one-to-one personal communications.

CVS Health’s Christine Sawicki shared how patient care can be improved through mobile technology and data devices. Utilizing a personalized approach to patient care delivers enhanced clinical value. Patients are comfortable sharing data. Secure messaging, interaction with a care team, and comprehensive reporting and alerts can help improve proactive patient care.

Interview by AJMC

The day ended with a presentation by Pramod John, PhD and CEO of Vivio Health. Dr. John challenged our thinking of how to drive better outcomes and lower costs using real-world data. Dr. John expressed that the real problem is that we don’t understand or use the data we have. Three things prevent us from getting to the best outcome: 1) It costs more than it should 2) Therapy has limitations and 3) Decision makers don’t understand or use the data. He went on to highlight that there’s a better use of data for specialty drugs: 1) Decouple the transaction cost from the cost of drug, 2) Assess the actual value based on the drug, and 3) Create a personalized & measured care path for each patient. Medicine is a science not an art. Dr. John ended his presentation by stating that “Often we think this is someone else’s problem. We all need to work together on how we solve the problem.”

Interview by First Report Managed Care



We had a great time in Minneapolis discussing the ever-evolving specialty pharmacy landscape. Below is feedback from some attendees:

“1st time – I’ll be back!”

“This Forum was FANTASTIC! Excellent speakers, fabulous topics! Timely and useful. Thank you for putting it all together.”

“Another great Forum!!”

“Enjoyed the conference!”


Don’t forget that PBMI is celebrating our 25th anniversary event in Orlando, Florida at the Rosen Shingle Creek hotel, March 2-4, 2020. Mark your calendars and stay tuned for details on registration, Excellence Award Program, and more.