The Coverage Wars Over Specialty Medications

AJPB® Translating Evidence-Based Research Into Value-Based Decisions®Specialty Pharmacy
Volume 2
Issue 6

I remember meeting with employers 10 years ago and telling them that specialty medications were the oncoming train that they would have to address.

I remember meeting with employers 10 years ago and telling them that specialty medications were “the oncoming train” that they would have to address. Some took my words to heart and began putting programs in place to address appropriate utilization for these useful but expensive medications. Others did not. Now, specialty medications have the atten

tion of just about all payers

because use of these medications is growing at 15%

to 20% annually.

Many employers and health plans placed these medications under the pharmacy benefit because they thought they could track and control them more effectively. They had their specialty pharmacies put in place many of the tools that have been used for traditional pharmacy benefit utilization management. Others kept specialty medications under the medical benefit because they believed that these medications are utilized in complex situations for conditions that require high levels of oversight.

The most common model that we see today is self-injected or oral specialty medications being covered through the pharmacy benefit and infused medications being covered through the medical benefit. Unfortunately, the costs and support programs associated with pharmacy and medical benefits tend to be very different, resulting in unequal benefits. This can create incentives both to game the system and to sometimes utilize a drug that is not the most appropriate one for the situation. I believe that we need to create a model in which all medications are managed by one organization, regardless of whether they are used orally, intramuscularly, or intravenously.

The old siloed delineations are no longer useful, and I would say neither appropriate nor safe. That model does not let us make the time-honored choice of “the right drug at the right dose for the right patient.” It does not focus on safety or appropriate value for a patient’s medical treatment.

I challenge all payers—whether health plans, employers, or pharmacy/specialty pharmacy providers—to work together to create patient-centric pharmacy models that break down false barriers. As you develop these evolving models, we hope you will share with us the outcomes of the programs as well as the lessons learned. All of us need to do our best to create a high-value pharmacy system.

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