Three Things to Know About Specialty Drug Costs & Utilization

Top 3 Things You’ll Learn

  1. How to apply UM strategies for high-cost specialty drug classes
  2. Why specialty medications need clinical oversight of in pharmacy benefits plans
  3. How to know if specialty drug costs and clinical quality are appropriate

There are a lot of essential and very expensive specialty medications on the market. If someone is taking a specialty medication, it is because that individual has a serious illness. It is assumed that they are getting the type of care they need, and everything is as it should be. Surprisingly, though, this is not always the case. Because of the high cost of specialty medications, providing detailed oversight to the specialty drug utilization in your self-funded clients’ pharmacy benefits plan provides a clinical and financial benefit to both members and the plan.

Specialty drug utilization management helps to ensure your clients are paying for the right drug for the right member in that condition. It also enables continuous monitoring of that member’s therapy response going forward. Here are three things about specialty drugs to consider when crafting your specialty utilization management and benefit plan design strategies:

  1. Dose Creep Can Occur Over Time

The anti-inflammatory class of drugs treat serious conditions, such as rheumatoid arthritis, psoriasis, and ulcerative colitis, to name a few. This class includes drugs like Humira®, Enbrel®, Cosentyx®, and Stelara®. To better manage this class of high-cost medications, it is appropriate to use prior authorizations with a dollar limit. The goal is not to create disruption. Rather, this strategy is used to review the clinical appropriateness of any increased doses or frequencies of these medications over time.

For example, if the physician feels it is necessary to increase the frequency or dose of the medication, a prior authorization with dollar limit ensures the plan has the opportunity to review the claim. The pharmacist reviewers could then verify that the reason for the dose increase aligns with FDA guidelines for that medication’s dosing and administration, or with industry standards of care. It could be that the patient is not responding to the therapy or that there are other factors to support the higher dose. Without a dollar limit on the prior authorization, these claims would not be flagged to ensure medication appropriateness and safety.

  1. Some Specialty Drugs Are Weight-Based Medications

There also are very expensive medications for hereditary angioedema and short bowel syndrome, which are severe conditions warranting therapy. Because these therapies can run in the range of several hundreds of thousand dollars, it is appropriate to monitor these medication claims in a similar way.

For example, with hereditary angioedema it is important to manage the condition using maintenance medications and acute therapies. When treating short bowel syndrome, the medication is weight-based, and dosing changes may be necessary as the patient’s weight fluctuates. A small dosing change may not only impact the clinical outcome for the member, but it also can be the difference in thousands of dollars for just one person.

  1. Several Specialty Medications Are Parity Priced

When a specialty medication is parity priced, the drug price is the same regardless of the dosage strength. Pomalyst®, for example, comes in 1 mg, 2 mg, 3 mg, and 4 mg strength. It is the same cost for a 1 mg as it is for a 4 mg dose, and it’s taken once per day. There is no clinically sound reason why someone should take four 1 mg tablets as opposed to one 4 mg tablet, and yet this is something we see occurring in pharmacy claims files today.

We have seen examples where changing parity priced dosing can save $400K-$700K on a single prescription for a single patient. See an example of Imbruvica® or another example of Afinitor®. These cases do not involve changing the drug nor changing the dose; just changing the strength and quantity dispensed can have a huge impact for a self-funded pharmacy benefits plan.

A person’s response to specialty therapy or their diagnosis can change. Specialty utilization management strategies should verify the prescribed dosing and frequency is clinically appropriate now and is monitored regularly over time.

Bottom Line

A person’s response to therapy can change over time or their diagnosis can change. It is important that specialty utilization management strategies help to ensure the therapy is appropriate, but those strategies should not leave the door open for unchecked dosing changes and continuation of therapy. It is critical to confirm that when your clients are paying for high-cost specialty medications, there is valid information to verify that they are getting the maximum clinical and economic value.

Download our free Clinical Strategies Playbook to learn additional best practices to help your clients manage specialty drugs and lower their prescription benefits costs.

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