Specialty drug costs have continued to escalate by double digits year over year, representing 35-55% of a plan sponsors total pharmacy spend. At the same time, less than 2% of the scripts drive upwards of 50% of the pharmacy plan spend. With these stats it’s no surprise that employers identified “managing specialty drugs” as the highest priority for benefit directors in a Midwest Business Group on Health survey.
To make matters worse, pharmacy benefit managers (PBM) who own the specialty pharmacy continue to complete their own prior authorizations for specialty drugs. Employers footing the bill should be concerned about this clear conflict of interest for the PBM. Employers don’t let hospitals complete their own pre-certifications for surgeries and they don’t let the hospital determine the length of stay. Employers use an independent pre-certification strategy for two obvious reasons patient protection from unnecessary surgeries and procedures and a fiduciary responsibility to the plan assets.
