Complex, innovative, and high-priced specialty drugs are entering the U.S. health care market at a rapid rate. In many cases, these specialty drugs offer the most effective—and in some cases, the only—treatment for illnesses and conditions that historically had few treatment options. Given their complexity, these drugs often require active clinical management, considerable patient education, and sophisticated logistical support for special administration, monitoring, and handling requirements. Patients taking a specialty drug often rely on enhanced clinical services to ensure safe use of the drug and optimize therapeutic outcomes.
Payers, providers, and patients have growing concerns with the cost and utilization of expensive specialty drugs. To address these challenges, payers rely on PBMs to manage the use of, and payment for, specialty drugs. PBMs offer techniques, including use of specialty pharmacies, to improve the quality and continuity of care that patients receive while also addressing overall costs.
PBMs manage prescription drug plans that include specialty drugs for more than 266 million Americans who have health insurance through a variety of sponsors, including commercial health insurers, self-insured employers’ plans, union plans, Medicaid, and Medicare plans. As such, PBMs are an essential partner to government, commercial, and individual payers in the health care system.
Over the next ten years, PBMs and specialty pharmacies will save payers and patients an estimated total of $250 billion on the cost of specialty medications and related non-drug medical costs when compared to what expenditures would be with limited use of PBMs and specialty pharmacies. PBM tools that have been used for years in the small-molecule drug categories to control costs are continuing to be successfully leveraged in the specialty drug category. The continued use of these cost-saving tools will be essential as PBMs and payers work to manage expenses and enable access to these innovative drugs.
White Paper: The Management of Specialty Drugs, sPCMA, February 2016
Pharmacy Benefit Managers (PBMs): Generating Savings for Plan Sponsors and Consumers, Visante, 2016, PCMA sponsored
High Cost Cholesterol Drugs Are Here: Are You Ready?, OptumRx, 2015