While specialty medications provide a new level of hope for people being treated for serious conditions such as multiple sclerosis, hepatitis C and cancer, the costs of these medications can be very high. In fact, only about 1% of members use specialty medications, but they contribute to nearly half of overall drug spend[1]. With new specialty medications entering the market every year, these costs can impact members and plan sponsors alike.
Below, we summarize our comprehensive approach to mitigate the financial impact of specialty medications while ensuring members receive the most benefit from their treatment.
1. Review the Pipeline and New Drugs
In 2022, the FDA approved 37 novel drugs[2], most of them being specialty medications. Even though a medication is approved by the FDA, FDA labeling is not enough. Appropriateness of therapy is key to eliminating wasteful spend for our clients while ensuring members have access to the medications they need.
Elixir starts by reviewing the clinical trial data, evidence-based literature and the safety and efficacy profiles to help determine the clinical effectiveness of the medication and if it is beneficial to your members for the condition it treats. Next, we balance this information with the economic impact of the drug to calculate cost effectiveness. Lastly, we assess the drug's availability in the market. Do members who need the drug have access to it?
After our thoughtful analysis of the new drug, Elixir decides formulary placement and where it makes the most sense for our member and the plan.
2. Implement Utilization Management Strategies
A proper utilization management strategy includes the development of evidence-based coverage criteria for appropriate prior authorization (PA) review. The PA process is a system of checks and balances meant to ensure the right drug, for the right member, at the right time and at the right dose. Determining PA criteria means asking about the medication’s appropriateness, if the member is a suitable candidate for the medication, is this the right phase of treatment to add this medication, and what are the dosing requirements based on all the evidence.
Elixir’s Prior Authorization process ensures a medication is the right fit for the member, can save a plan thousands of dollars in wasteful spend and, most importantly, sets the member on the best path to better outcomes.
3. Predict the Financial Impact
Whether it’s a new specialty drug to market, a new or expanded indication for an existing medication, or a generic or biosimilar becoming available, preparing for the financial impact helps mitigate risk. Elixir works with your plan to consider the following:- The number of members who might use a particular drug
- The prevalence of a disease in your members
- The expected cost of the new drug
- The new drug's cost-effectiveness compared to other drugs already on the market to treat the same condition
- The impact of a generic drug entering the market
- Per member per month (PMPM) costs
- Cost shifts when additional treatments are approved
With this analysis, we can help you minimize surprises to your specialty spend, while ensuring members get the medication they need.
4. Provide Individualized Care
Just as specialty medications are unique, so are the needs of the members receiving them. From side effects to storage requirements to dosing schedules, it’s critical to provide members one-on-one time with a pharmacist or clinical professional throughout their treatment.
Elixir Specialty Pharmacy care coordinators provide the individualized care that will set a member on a path to successful treatment before taking their first dose and throughout their entire treatment. With a care coordinator’s guidance, the member will know what to expect with their medication and stay engaged and adherent to their treatment plan, which can lower the total cost of care.
Together, these four strategies provide a proactive, hands-on solution that helps you manage plan costs and balance the unique needs of members utilizing specialty medications. For more details on the Elixir approach, download the full e-book, Four Strategies to Successfully Manage Specialty Medications.
[1] Seymore, Brandeis (2020). Challenges of Channel Management for Specialty: Medical Benefit or Pharmacy Benefit. Pharmacy Times. July 10, 2020. https://www.pharmacytimes.com/view/challenges-of-channel-management-for-specialty-medical-benefit-or-pharmacy-benefit.
[2] U.S. Food & Drug Administration. Novel Drug Approvals for 2022. https://www.fda.gov/drugs/new-drugs-fda-cders-new-molecular-entities-and-new-therapeutic-biological-products/novel-drug-approvals-2022.
