Specialty benefit design and management tools employed by pharmacy benefit managers can help control specialty drug spending and ensure optimal patient care.
The increasing utilization and costs of specialty drugs will have a substantial impact on overall health care costs during the next decade.
Pharmacy benefit manager (PBM) tools that have successfully controlled costs in the traditional small-molecule drug categories will be critical to manage the increasing costs and requirements of the specialty drug category, according to a study published by sPCMA, a division of the Pharmaceutical Care Management Association.
Financial Impact of Specialty Drugs: Current and Projected
In 2014, more than 500,000 Americans filled prescriptions with a value of at least $50,000. This data represents a 63% increase from 2013.
Specialty drugs, primarily biologic agents—such as adalimumab (Humira), sofosbuvir (Sovaldi), and glatiramer (Copaxone)—that treat inflammatory conditions, hepatitis C, and multiple sclerosis (respectively), among others, increasingly account for a significant proportion of overall health care spending.
It’s been estimated that by 2020, 9 of the 10 best-selling drugs (by revenue) will be specialty drugs that treat conditions such as those illustrated in Figure 1. The estimates also indicated that specialty drug spending could reach $400 billion, or 9.1% of national health spending.
However, revised estimates point to the increasing prevalence of biosimilars in the market. Biosimilars are anticipated to curtail the overall biologic market value growth by reducing specialty drug spending to $262 billion by 2019, according to sPCMA.
Specialty benefit design and management tools employed by PBMs will also play a significant role in controlling specialty drug spending, as well as ensuring optimal patient care and support.
Target Conditions for Specialty Drug Treatment
Estimated Treatment Costs
$100,000 per course of therapy
Specialty Benefit Design and Management
Specialty drugs frequently have unique shipping and storage needs, as a result specialty pharmacies are better equipped to procure, store, and dispense these treatments than traditional retail pharmacies. Furthermore, pharmacists and personnel at specialty pharmacies provide patient education and clinical support beyond the capabilities of a retail pharmacy.
The tools in the PBM arsenal are critical to ensure appropriate care for patients needing specialty drugs while managing the often extraordinary costs. A brief sampling of key tools follows:
Comprehensive management approaches that monitor and balance patient care outcomes and costs will help PBMs ensure that new, innovative medications are readily available and affordable to the patients who need them most.
Through the use of specialty pharmacies, utilization management tools, adherence and compliance programs, and preferred specialty pharmacy networks, PBMs may continue to provide a superior level of service to patients, providers, and payers.