Ask an Adviser: How can we cut specialty pharmacy costs?

Welcome to Ask an Adviser, EBN’s weekly column in which benefit brokers and advisers answer (anonymous) queries sent in by our readers. Looking for some expert advice? Please submit questions to askanadviser@arizent.com. This week, we asked Michael Baldzicki, executive vice president of growth and strategy for AscellaHealth, to weigh in on the following:How can we cut specialty pharmacy costs? 

Employers should consider carving out prescription medical and/or pharmacy benefits from their major pharmacy benefits management plan to contract directly with a specialty pharmacy services provider. Carve-out plans give employers better control over specialty pharmacy benefit costs, which is a crucial consideration as costs continue to rise.

They give employers greater transparency into their benefit claims and allow them to gain greater understanding and control of specialty pharmacy spending by rethinking contractual partners. Another advantage is an ability to negotiate better deals by understanding the data and medical Rx claims. This strategy ensures clinical and financial programs perform as promised, while it’s also important to adopt employer-to-employee communication to drive specialty drug cost containment and medication compliance.

Read more: Ask an Adviser: How can pharmacists improve care by picking up where PBM services leave off?

What’s more, carve-out plans offer employers direct access to specialty pharmacy providers who are knowledgeable about specialty pharmacy benefits and have a focus on rare ultra-orphan products and gene or cell therapies.

Employers that implement a carve-out for specialty medications through plan language and benefit design can achieve an average savings of 5% up to 30%.They can also enhance the patient journey with innovative clinical programs and services that are designed to improve adherence. This includes a call center composed of experienced patient care coordinators knowledgeable about specialty conditions, including orphan and ultra-orphan diseases.

It’s also important to find a partner that offers technology-based communication tools and algorithms to seamlessly engage patients, break down barriers to medication access and ensure optimal therapeutic outcomes.

In addition, employers should partner with a specialty pharmacy services provider that offers a suite of unique financial assistance programs for high-cost gene or cell therapies and other expensive specialty medications. Patient care coordinators and pharmacists offer the broad specialty therapeutic expertise needed to rapidly identify copay assistance and other financial resources necessary for patients to start and stay on therapy as prescribed.

Read more: 3 reasons to optimize pharmacy benefits before the next open enrollment

Consider the case of TEPEZZA for thyroid eye disease. An infused product that was being administered in a hospital outpatient facility billed the third-party administrator (TPA) of a plan sponsor for a total cost of therapy at $1.3 million. Our company redirected the site of care to an in-network infusion center and white-bagged the product, with a total therapy invoice to the TPA at $404,000 — a difference of more than $950,000 based on our site-of-care infusion program.

The ideal specialty pharmacy services provider should serve as a collaborative and consultative partner, offering state-of-the-art clinical programs and financial services. A carve-out should be designed to provide members with seamless access to limited drug distribution therapies, improve clinical outcomes, optimize the overall therapy journey for specialty patients and provide cost-savings solutions for employers and other payers.