The specialty pharmacy industry produces drugs that are among the most expensive on the market. Because these medications are so costly, the industry has been working to put several strategies in place to help control costs.
To be considered a specialty drug, a medication generally has to have one or more of the following characteristics – its purpose is to treat a complex or chronic condition or a rare or orphan disease, patients need more education and support to take the drug, it is costly, or it has special storage or shipment requirements.
Cost Reduction Strategies
Because specialty drugs are so expensive, terms and conditions of payment are clearly outlined in a payer contract to help keep costs down. When pharmacy benefit managers (PBM) draft contracts, they include pricing models and rebate guidelines for insurance plan sponsors or payers that also include a specialty drug formulary.
Payment of Claims
Another strategy for reducing costs involves the payment of pharmaceutical claims. Payment of claims for specialty drugs goes through a PBM in a carve-in or carve-out model. An employer deals directly with a medical health plan carrier for medical and pharmacy benefits in a carve-in. The insurance carrier will either oversee the benefits administration itself or contract with a PBM to process the pharmacy benefits and administer the pharmacy plan. In a carve-out, the employer deals directly with a PBM to handle the administration of pharmacy benefits.
PBMs can control costs for specialty drugs when they process claims by using National Drug Codes. These codes have a precise numbering system that enables PBMs or other payers to track and control dosage levels, how much is dispensed, and how often the drugs in the specialty formulary are taken.
Another way of controlling costs is through utilization management. This approach also highlights the importance of tracking dosage and dispensing amounts of specialty drugs. PBMs and payers can use utilization management methods, such as prior authorization and step therapy, to make sure that medications are used appropriately and manage overall cost.
Clinical management programs are another way of controlling costs. These types of approaches focus on monitoring patient behavior during therapy. An example of this type of control is a medication adherence program. Healthcare providers communicate with patients throughout their therapy to make sure they are taking the drugs when they are supposed to.
A related cost control measure is patient counseling, which focuses on helping patients handle the adverse effects of the drug therapy and, as with clinical management, provides the support the patient needs to maintain the therapy as needed.
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