Specialty drugs, those defined as costing more than $10,000 per patient per year, have revolutionized the management of some disease categories and improved health outcomes for patients. The complexity of these drugs, including specialized administration and monitoring, additional training requirements and small patient populations has also resulted in significant pressure on employers and their drug benefit plans.
By considering and implementing a proactive and multi-pronged approach, employers can improve their drug benefit cost-effectiveness while still supporting positive health outcomes for plan members.
Balancing clinical access and costs
Giving plan members access to important medications while controlling costs can start with careful clinical and financial management tools including:
- Managed formularies – offer a list of medications that provide the most cost-effective and evidence-based options. Currently, less than 20% of plan members are currently covered under a true managed formulary.
- Prior authorization and step therapy – make it standard to confirm pre-established indications and criteria, along with identification of lower cost alternatives where available. This ensures that the right medication is prescribed at the right time for the right conditions.
- Biosimilars – with cost savings of up to 50% over originator biologics, the use of biosimilars provides tremendous cost savings potential.
- Provincial integration – coordinate your benefits plan with your provincial plan to integrate coverage for conditions already reimbursed under provincial programs and Pharmacare.
- Maximum allowable cost (MAC) programs and caps on drug markups – help control costs for employers and plan members and mitigate future cost increases as patients cycle through various medications.
A role for specialty pharmacies
Specially trained healthcare providers at specialty pharmacies offer patients important services including integrated refill reminders, comprehensive care management programs and patient coaching calls. Research shows that patients using specialty pharmacies have increased adherence and lower abandonment rates compared with patients who don’t use specialty pharmacies.
A multi-pronged approach
Maintaining the balance between providing access to effective specialty drug treatments while responsibly managing costs is possible but it requires a thoughtful and multi-pronged approach.