Explore Value-Based Arrangements to Mitigate Specialty Drug Costs

Specialty Drugs

• Costly medication delivery e.g., temperature control
• Complex treatment administration e.g., infusions
• Complex molecule composition e.g., biologics
• High cost e.g., CMS uses $600/mo

Standard of Care for Chronic Conditions

• Rheumatoid Arthrits
• Psoriasis
• Multiple Sclerosis
• HIV/Aids
• Many Cancers

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Specialty medications may be covered under the pharmacy benefit or under the medical benefit.

Applying V-BID to Specialty Medications

• Impose no more than modest cost-sharing on high-value medications
• Reduce cost-sharing in accordance with patient or disease specific characteristics
• Relieve patients from high cost-sharing after failure on a different medication
• Use incentives to encourage patients to select high-performing providers and settings for their care

+Waste-free formulary excludes no-added-value, high-cost drugs. +Some medications require a second opinion. +Clinical indication based on FDA approval will be enforced via pre-authorization. +Infusion services must be obtained in an infusion center, doctor's office, or at home unless it is determined that it is medically necessary to administer them in a hospital setting. +Use of coupon cards is banned. Accumulator programs will be applied. +Chronic care maintenance drugs have no cost share.

Barriers

• Plan design and prescribing physician adherence to evidence based medicine
• Administrative complexity
• Ownership dilemma

Actions You Can Take

Think in terms of the total cost of care.

Work to integrate your pharmacy and medical data with outcomes.

Strive to improve the consumer experience.

Evaluate Contract Terms

• Hire an independent expert
• Require providers to use NDC codes for specialty
• Review the rebates
• Know how PMPM is calculated

Monitor site of care and work with vendors and patience to assure drugs are administered in the highest value setting.

Review Clinical Utilization Management

• Prior-Authorization
• Step Therapy
• Step Edits
• Channel Management
• Patient Adherence

Use a center of excellence program to drive patients to high-value providers/settings.

Consider carving specialty pharmacy out of your PBM.