By now everyone knows that the biggest issue in regard to drug use and costs is specialty medicines that are often complex to make biotech drugs and usually require some special attention for administration, either by injection or infusion. They also may often be covered by a medical benefit instead of the drug benefits, adding to the complexity of their management. The EMD Serono Specialty Digest gives one of the best looks at trends in regard to this category of drugs. Over 100 health plans participated in the survey, representing a large percent of overall covered lives. (Specialty Digest) The three major issues highlighted in the report are management, particularly within medical benefit drugs, member cost share and adherence to avoid waste and ensure the outcomes intended from use of these usually expensive pharmaceuticals. Within management, three primary strategies are the site of care, creative provider reimbursement and use of clinical pathways. More than 85% of plans cover self-administered agents under the drug benefit, while infused or injectables that require provider involvement are typically a medical benefit. 51% of commercial plans have unique cost sharing approaches for specialty drugs, but these plans cover only about 32% of the health plan lives; and 55% of plans have a separate cost share for medical benefit drugs. Coinsurance appears to be becoming more popular as the primary cost share approach. Cost sharing for specialty drugs can be quite large and there are regulatory threats to limit this cost sharing, which of course will only drive up premiums for everyone. Plans are also tending to introduce more tiers of cost-sharing for this category of medicines. Many plans do protect the member to some extent with a maximum out-of-pocket amount. Part D Medicare plans have less flexibility under current rules.
