Specialty medications.

A phrase that strikes fear into the hearts of employers. We want our employees to get the care they deserve and need, but why do specialty medications have to make it so costly?

While specialty medications refer to a broad range of meds, according to the PCMA, a specialty drug possesses any number of these common attributes:

• Prescribed for a person with a complex or chronic medical condition, defined as a physical, behavioral, or developmental condition that may have no known cure, is progressive, and/or is debilitating or fatal if left untreated or under-treated;
• Treats rare or orphan disease indications;
• Requires additional patient education, adherence, and support beyond traditional dispensing activities;
• Is an oral, injectable, inhalable, or infusible drug product;
• Has a high monthly cost;
• Has unique storage or shipment requirements, such as refrigeration; and
• Is not stocked at a majority of retail pharmacies.

Since specialty medications can fall under a number of categories, it can feel like a moving target when trying to manage those costs or prevent them from continuing to rise. So how can employers effectively address the impact that these various medications have on their overall pharmacy spend?

Manage the Prior Authorization Process

Listen to our team talk about managing the Prior Authorization process and how your PBM should approach it! Skip forward to 19:50 – 23 where we answer, “What does the Prior Authorization (PA) process look like?”

Align your Incentives

A lot of PBMs actually make more money when members fill specialty medications.  If your PBM retains the plan’s rebates, they are actually incentivized to let high-cost medications be filled. 

Be sure your PBM makes the same amount of money, ideally through an up-front administration fee, no matter if the medication costs $1 or $4,000. 

Take a Creative Approach

Finally, when it comes to specialty medications, you need to work with a partner who knows how to really think outside of the box. 

If you’re an employer who currently has a large number of members on specialty medications, you need to work with someone who has approached this from new angles, whether that be creating a specialized program just for you or bringing qualified partners to the table to help navigate the best options for your business.