Specialty Prescription Drugs 101 – What You Need To Know

Specialty Prescription Drugs 101 – What You Need To Know

Jul 11 2017

Prescription drugs are known to be a key driver of escalating health care costs.

Specifically, specialty drugs have received increased attention because of the significant impact their high prices have made on the cost of health care.  

In fact, recent studies indicate that specialty medications account for 85 percent of overall health care costs. This growth is powered by increased medication combinations, a larger population suffering from conditions that need specialty drug treatments, as well as uncoordinated process and delivery systems.

Which prescriptions are considered specialty drugs?

Specialty drugs are often biologics or drugs derived from living cells that are injected,  infused or ingested orally. These prescriptions require careful handling, provider coordination and patient education for safe and effective use. In order to prescribe this type of medicine, the physician must first request permission from your health insurance company to ensure it falls under the benefits outlined in your plan and they can then only prescribe a 30 day supply at a time. Specialty drugs are only dispensed through home delivery or specialty pharmacies. These pharmacies employ highly trained teams of pharmacists, nurses and clinicians who work with doctors and patients to make sure these complicated medications are administered correctly.

Conditions that may require treatment with specialty medications include:

  • Crohn’s disease
  • Hemophilia
  • Hepatitis B
  • Hepatitis C
  • Infertility
  • Immune disorders, such as Guillain-Barré syndrome or lupus
  • Kawasaki disease
  • Multiple sclerosis
  • Plaque psoriasis
  • Rheumatoid arthritis
  • Respiratory Syncytial Virus (prevention)

The average annual cost of a specialty drug is $53,000. And because of these high-cost specialty drugs across the industry, roughly one percent of patients account for nearly 40 percent of drug costs. This will continue to be an increasing trend as there are 7,000 new specialty drugs in the pipeline.

How do we reduce the cost of specialty drugs?

To increase affordability and reduce prescription drug costs, health plans partner with Pharmacy Benefit Management (PBM) or third party administrators to manage both traditional and specialty drug benefits and utilization. With specialty drugs, PBMs manage patient access to these medications, while working with specialty pharmacies to provide advanced clinical management programs that ensure the value of therapy is being optimized at the lowest possible cost.

Over the next decade, specialty pharmacies – pharmacies that have the services to manage the handling and service requirements of specialty drugs including dispersion, distribution and case management – are expected to save consumers, employers and governments programs approximately $250 billion. Each provider or health plan has a listing of specialty pharmacy within their network.

If you suffer from these diseases, here are some things to consider for helping reduce costs:

  • Develop a strategy to control pharmacy costs. The cost of specialty drugs is expected to quadruple before 2020. A thorough update of your benefits and utilization guidelines will help your wallet now and over the next three years.  
  • Check your health plan for a pharmacy management program. Priority Health’s Medication Therapy Management (MTM) is a service that leverages pharmacists to help individual patients get the best results from their medications – whether it’s ensuring correct dosage and usage, potential interactions between drugs and any cost saving alternatives. This program has seen significant success. In fact, in 2016 there was an average savings of roughly $24 million for both the Medicare and commercial markets.
  • Use tools. More and more health plans are helping their members with cost transparency. Priority Health’s Cost Estimator tool includes the costs of procedures to help drive health care costs down, that has saved members a total of $6.3 million. Later this year, the tool will integrate pharmacy features to share drug prices before prescriptions are filled.

While specialty drugs are one of the highest costs for consumers, there are ways to manage and curb costs. By looking into programs and tools available with different providers, there are ways to avoid over overpaying for essential medications.