Pharmacy Benefit Management Institute Conference Highlights - Part 3

Specialty Drug Management Initiatives

With nearly half of specialty spending occurring on the medical benefit in 2012, and seeing that specialty spending is predicted to account for 50% of total pharmacy spend by 2019, Mike Waterbury, president, ICORE Healthcare, specialty division of Magellan Pharmacy Solutions, reports that specialty drug costs will surpass traditional spending costs in the next few years. Although the trend is well known to many employers, many are not prepared with management strategies that will deliver high-quality, cost-effective specialty care.

“Are you looking at the drug or the condition?” Mr Waterbury asked attendees. 90% of payers said they focused on specific drugs when asked if strategies focused more on specific drugs or cancer therapeutic category (such as breast cancer or lung cancer).

The 2013 Medical Pharmacy & Oncology Trend Report (www.icorehealthcare.com/icore-resources/trend-report.aspx) surveyed 48 top US commercial health plans that represent over 166 million lives. Read more here.

Implications of the Health Insurance Exchange Marketplace and State Law Trends on Commercial Pharmacy

Presenters in this talk focused on how the creation of health insurance exchanges (HIEs) and other federal and state regulations will impact the provision and administration of pharmacy benefits. Laurel Wala and Cami Agena, members of the Phoenix Law Group of Feldman Brown Wala Hall & Agena, both addressed what the new reform requirements will mean, as well as what the consequences of not meeting them might be.

The first question they raised was, are Quality Health Plans (QHPs) commercial plans, or are they federal healthcare programs? According to the presenters, a letter from Kathleen Sebelius, secretary of the US Department of Health and Human Services (HHS), said that the agency does not consider QHPs to fall under the definition of federal healthcare programs. However, with time, HHS has promised a “robust oversight” of Affordable Care Act programs. Read more here.

Copayment Coupons and Patient Assistance Programs: Just 1 Piece of the Specialty Drug Management Puzzle

Pat Gleason, PharmD, FCCP, BCPS, director of health outcomes, Prime Therapeutics, and Shelley Sanchez, senior director of specialty product development, Prime Therapeutics, presented on one approach to managing the specialty drug benefit, which includes optimizing the use of PhARMA manufacturer coupons and patient assistance programs (PAPs). Prime Therapeutics research is particularly focused on trends and findings that coupons and PAPs have on patients’ out-of-pocket (OOP) costs. Prime has always had a unique focus on specialty drug management. Its unique connections, medical data, and pharmacy data all result in “superior member experiences” and more affordable medications. Read more here.