Any survey of plan sponsors makes it abundantly clear – effectively managing specialty drug costs continues to be a top priority! For the Employers Health book-of-business in 2020, specialty drug claims represented 1.4% of total claims and drove 47% of gross cost. There are a number of actions we are taking in 2021 and beyond to help our clients better manage this growing spend.
Specialty drug price inflation accounted for 7.3% of the overall increase in specialty drug spend, pre-rebate. With each annual market check, we focus on ways to improve the unit prices of specialty drugs through combinations of improved discounts, rebate guarantees, formulary options and contractual definitions.
HIGH PRICE DRUG OVERSIGHT
The clinical team at Employers Health looks each week at those medications filled and reimbursed under our book of business that hit certain dollar thresholds. For new fills, we work to understand the approval process and the potential duration of therapy and communicate this information to clients. For refills, we look for opportunities to check-in with patients and providers to ensure that medications are accomplishing their desired clinical effects.
SPECIALTY PRIOR AUTHORIZATION OVERSIGHT
Our clinical pharmacists work with each contracted PBM to understand the criteria used for determining whether a specialty drug is right for a particular patient and how those criteria compare to other plans in the market. In cases where we believe tighter criteria are appropriate, we work with the PBM to understand the impact and administration of such changes on both the financial guarantees and the patient experience. The clinical team regularly monitors PA approval rates by drug and indication.
SPECIALTY PRIOR AUTHORIZATION “SECOND OPINION”
Hearing the desire from our clients to offer third-party options for specialty prior authorization services, we worked with our PBM suppliers to integrate a concurrent process that offers plans a “second opinion” on approvals for specialty medications that cost more than a certain threshold. Contracting with ELMC and US-RxCare, clients can opt to have clinical pharmacists at these third-party organizations review certain high-cost specialty medication approvals made by the PBM and ensure that the PBMs’ own criteria has been adequately met, documented and followed-up on. While the PBMs have a high level of accuracy in their prior authorization process, we know that with the climbing annual cost of specialty medications that finding only a few opportunities for edits can save a plan significant dollars. This service also doesn’t require additional administration for the patient or plan sponsor and preserves rebate guarantees.
VARIABLE COPAY PROGRAMS
The explosion of copay assistance programs has presented an opportunity for both plan sponsors and patients to benefit. For qualifying plans, a variable copay strategy can provide additional savings to plans through accessing more or all of a particular drug’s annual copay assistance dollar threshold. At the same time, participants benefit from a zero dollar copay for medications included in the program. Early results from Employers Health clients that participate in CVS’ PrudentRx solution show plans saving a significant amount of their specialty pharmacy spend while providing an enhanced benefit for participants. Better yet, plans still qualify for the rebate guarantees outlined in the contract. Clients in the OptumRx and Elixir contracts are also beginning to evaluate and implement similar strategies and we are eager to see the results. Every day, the team at Employers Health is analyzing our book-of-business data and evaluating potential solutions to help our clients curb their specialty spend while balancing the need for savings with administrative feasibility and participant disruption. Our current priorities focus on ensuring that clients implement sound clinical management strategies and benefit from market opportunities as they present themselves.