pecialty drugs are high-cost prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis, in addition to very rare “Orphan” Diseases (i.e. “Bubble Boy” disease). Specialty drugs often require special handling (like refrigeration during shipping) and administration (such as injection or infusion). Patients using a specialty drug often must be monitored closely to determine if the therapy is working and to watch for side effects.
Specialty drugs can be covered through either the members medical or prescription drug benefits.. How a specialty drug is covered usually depends on where the patient receives the drug. If the patient takes a pill or self-injects the drug at home, it is more likely to be covered through his or her prescription drug benefit (managed by the PBM). If the patient receives the drug at a doctor’s office or an outpatient clinic, it’s more likely to be covered through the medical benefit (managed by the Medical Management Vendor).
Specialty Drugs: What everyone agrees upon
Specialty drugs are very expensive – $1,000 or more per month – and spending on them is growing 15 to 20 percent a year. Some are very expensive, with the Hep C treatments hitting the market at $94,000 per treatment. With the orphan drugs, its gets worse, one example being a $500,000/year treatment for the enzyme replacement therapy, PEG-ADA, a condition similar to bubble boy disease. Worse still – a new drug will be hitting the market soon that will cost $1MM per treatment!
Specialty Drugs: What no one agrees upon
While we all agree it’s morally important to “cure” people if we have to medications to make it happen but the question is “How? With definitive, scarce resources how does a program manager build a model that offers members what they need for benefits but is sustainable year after year? The opinions vary greatly and some of the ideas being floated around behind scenes are too embarrassing to discuss.
The Sawgrass Way
Like we do with Medical Claims, we have very involved conversations with our Medical Management, Pharmacy Benefit and Specialty Drug vendors (which is much easier to do when you build your own products). Looking beyond Step Therapies, Split Fills and Pre-authorizations, we ask questions that many other program managers don’t appear to be asking. Some very basic questions about a new specialty drug coming to market would include, but not be limited to: