EMD Specialty Digest III

One benefit of the rapid growth of specialty drug pipelines is that payers have the opportunity to select preferred agents, on which they typically get better pricing.  Almost 80% of plans have preferred drugs in at least one category.  The most popular categories for preferred status are growth hormones, arthritis, Crohn’s disease, multiple sclerosis and hepatitis C.  Another evolving strategy is to limit supply to less than 30 days, to ensure that a patient can tolerate a compound without wastage.  Oncology has been a particularly costly therapeutic category.  Payers are developing special approaches to use of drugs for that indication, including use of clinical pathways, requiring confirmed clinical trial evidence for the indication, using lower-cost sites of administration for infused and injectable agents, promoting use of palliative and end-of-life programs and adjusting fee schedule to incent use of low-cost drugs.   Companion diagnostics which determine if the patient has a tumor that is likely to be affected by the drug are also increasingly being mandated.

Because these compounds have complex handling, distribution, administration and payment requirements, most plans have at least one specialty pharmacy vendor that they work with and many plans have mandated use of such a vendor.  There is a slight trend toward use of fewer vendors.  Over 60% of plans mandate use for at least one therapeutic category under the pharmacy benefit and about 30% do so for the medical benefit.  Plans are generally moderately satisfied with their vendors, with the least satisfaction in the area of outcomes.  And increasingly plans are collecting and expecting the collection of outcomes, so that they can assess the value delivered to patients.  Plans are also very interested in independent comparative effectiveness research to help guide their coverage of specific drugs.  Looking to the future, the trend plans most expect are increased patient cost shares and more use of clinical pathways.  In regard to the first, it should be noted that many states are considering legislation that would limit patient costs, which means payers costs, and premiums, will go up.