The Employer's Guide Blog for Overseeing PBMs

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Specialty Drugs: A Five Pillar Approach to Managing Cost

What is a Specialty Drug? Well readers, that is the $218 billion inquiry. As indicated by IQVIA, that was the measure of the 2018 specialty drug spend. This represented over 48% of medication spend for the entire pharmaceutical industry for that year. In spite of the fact that costs have been a pointer of what qualifies as a specialty drug previously, clinicians would contend that a medication ought to be characterized by its clinical viability and not its expense. Specialty medications can have a few attributes including however not restricted to:
  • Treats chronic, complex, or life-threatening conditions
  • Usually manufactured through biologic processes and/or targeting a specific gene
  • Costs more than $800/month
  • Requires intensive clinical monitoring, complex patient actions, and/or special handling
  • Although most commonly injected or infused, they may also be taken orally or inhaled 
Aspirin (non-biologic) vs. Monoclonal Antibody (biologic)
Yet, cost is still a prominent characteristic of determining what is viewed as a specialty drug. In light of this, managed care associations have started to execute systems so as to adequately deal with the excessive measure of spending and cost that encompasses this significant yet costly part of pharmacy. These methodologies are contract transparency, claims adjudication, utilization management, disease management, and patient education.

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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