The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

Channel Management for Specialty: Challenges with Medical Benefit or Pharmacy Benefit

At the point when the vast majority consider getting their meds filled, they take their script to their nearby network drug store or send their script to a mail order pharmacy. As a rule, by far most of prescribed drugs are usually secured under the pharmacy benefit in the interest of the individual’s insurance plan. 
Albeit a retail or customary mail channel bodes well for 97% to 99% of non-specialty medications, the other 1% to 3% of scripts are specialty drugs that may should be filled through another channel including home infusion, physician clinic or a hospital. With specialty medications, there is dilemna in which either the medical or pharmacy benefit may be the primary point for dispensing, administration, and reimbursement.


In recent years, as the industry has watched specialty spend grow, I have observed prescription insurance plans’ specialty gross costs represent anywhere from one-third to 50% of their total gross spending while the number of prescriptions being filled for that specialty spend is for fewer than 1% of the health plan’s total pharmacy prescriptions.
According to CVS Health’s 2018 Drug Report and the cohort of insurance plan’s it manages, “Specialty utilization and share of gross cost continues to grow, reaching 45 percent of total pharmacy spend in 2018 as compared to 42% in 2017, despite comprising only 1 percent of prescription claims.”

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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