Specialty drugs have taken center stage in recent years, making up 80% of all newly approved medications by the FDA. These groundbreaking medications hold the potential to elevate the quality of life for patients with complex conditions. But, of course, there’s a catch. They come at a steep price. Although specialty drugs make up just 1-2% of prescription volume, they are responsible for a whopping 50% of total pharmacy spend.

As the pipeline for high-cost specialty drugs continues to grow for common conditions such as asthma and diabetes, self-funded employers will increasingly bear the burden of this trend. It underscores the need for a pharmacy benefit manager (PBM) who uses an effective, high-touch strategy to manage the utilization and costs of specialty drugs that:

Drives members to the lowest-priced medications.

Controlling runaway specialty drug prices, some soaring into six figures annually, is a big issue for employers looking to cut spend. To tackle the problem, PBMs must prioritize including cost-effective drugs on their formulary. By offering generic and therapeutic alternatives for expensive specialty medications, members and plan sponsors experience significantly lower Rx costs. PBMs with care navigation have clinical pharmacists who proactively guide patients toward high-value alternatives when appropriate, reducing costs even further.

Place patients at the forefront of their care.

Managing specialty conditions can be difficult and time-consuming for members. PBMs with high-touch pharmacy guidance build trusting relationships with members and proactively uncover additional care needs. Pharmacists equip patients with the information to ask important medication questions, voice concerns, and collaborate meaningfully with their entire pharmacy team. Beyond education, pharmacy guides improve outcomes by monitoring each step of a patient’s Rx journey, ensuring adherence to specialty medications, and promptly addressing any drug concerns or side effects that may arise.

Embrace the future of specialty medications.

As newer, more advanced drugs enter the specialty medication market, PBMs must adapt to provide the highest-value treatments to members and rein in costs. Biosimilars are like generic versions of specialty medicines, but they have the same safety and effectiveness as the innovator drugs. PBMs can identify biosimilar alternatives and substitute these drugs, resulting in significantly lower Rx spend. Alternatively, emerging gene and cell therapies bring significant uncertainties and hefty costs, potentially reaching $2 million per therapy. PBMs must prepare clients for the potential financial impact of these therapies to help them make the most informed decisions for their teams.

Balancing the exorbitant costs associated with specialty medications is as complex as the conditions they treat. While PBMs have the power to strike a crucial balance between the care needs of their specialty members and the steep costs involved, not all of them are willing to relinquish the financial gains associated with these expensive drugs. PBMs that prioritize transparency and best-in-class member support can pave the path to a better Rx experience for your members and your bottom line.

Curious about Rightway’s approach to specialty medications? Get in touch with us.