WHAT ARE SPECIALTY DRUGS AND HOW CAN A PBM HELP YOUR PLAN MANAGE ACCESS TO THESE DRUGS

Due to their very limited and targeted nature, specialty drugs are not often seen by many pharmacists and most patients. But that's changing fast, as the pharmaceutical industry turns to treating some of our most deadly and chronic diseases: cancer, HIV, hepatitis C, hemophilia, Crohn's disease, multiple sclerosis, plaques and rheumatoid arthritis.

Specialty drugs are expensive drugs and require “high contact” patient service, as well as specialized storage, handling and delivery requirements. When a care situation requires a physician to prescribe a specialty medication, it is important that your PBM is able to navigate the sometimes difficult path to a successful prescribing experience.

What are specialty drugs?

The Pharmaceutical Care Management Association defines a specialty drug as:

The definition of a specialty drug continues to evolve as the specialty drug portfolio progresses and expands. These drugs are best defined by the full range of attributes of each product, rather than solely by cost and route of administration. A specialty drug has one of these common characteristics:

• Prescribed for a person with a complex or chronic disease, defined as a physical, behavioral or developmental condition which may have no known cure, which is progressive and/or debilitating or fatal if left untreated or under -processed;

• Treats indications of rare or orphan diseases;

• Requires additional patient education, adherence and support beyond traditional dispensing activities;

• It is an oral, injectable, inhalable or infusible drug;

• It has a high monthly cost;

• Have unique storage or shipping requirements, such as refrigeration; and

• It is not stocked in most retail pharmacies.

Most of the time, a specialized drug has been prescribed for a patient with a very serious illness. As a result, strong emotions can come into play during the specialty drug approval process.

The best advocate the plan sponsor and the patient can have in this situation is a PBM who has extensive experience in managing access and payment for the drug in question.

Breakthrough, innovative drugs with a price to match

These drugs, which can cost $1,000 or more per month, can often make a difference in life or death for the patient. Therefore, each case must be approached and assessed individually.

According to William Lineberry, PharmD, BCGP and Vice President of Clinical Pharmacy Programs and Associate Director of Acquisitions at VativoRx, VativoRx's approach is different from other PBMs. “First of all, we don't own a pharmacy,” he says, “so there's no financial conflict or incentive for us to approve the prescription. Second, because of this, we can evaluate the specialty drug purely on a clinical basis. Does it do what it says? If there are multiple drugs available for the disease, is this the best option for the patient at the time they need treatment? Have other approaches been tried?

“Unlike some of our larger competitors, we don't just approve pre-approval requests for specialties. We ensure that each specialty drug approval is clinically appropriate, based on the patient's diagnosis and treatment history, and used for an appropriate duration according to evidence-based guidelines. Last but not least, our goal is for each patient to understand both their illness and the prescribed treatment, including how to store and use the medication, what to generally expect from it, and the potentially significant side effects to be aware of. . . that require a follow-up call to the patient's prescriber."

Specialty drugs are becoming more commonly prescribed

Although less likely to be widely prescribed, specialty drugs are rapidly increasing their presence. According to Pharmacy Times:

The rate of increase in spending on specialty drugs far exceeds the rate of increase in spending on other drugs. This is the fastest growing segment of drug spending under pharmacare. Over the next 5 years, specialty drugs are expected to account for 50% of total drug spending, or approximately $250 billion.

As research into rare and complex diseases continues, more specialty drugs are coming to market. In the mid-1990s, there were fewer than 30 specialty drugs, while there are now over 300 specialty drugs on the market. Currently, most drugs in development are specialty pharmaceuticals, especially oncology agents.

The federal government has prioritized research to help patients with rare and complex diseases by approving incentives, such as Fast Track and Priority Review, to expedite the approval of new drugs.

Since specialty drugs represent a higher percentage, both in cost and number, of the total number of prescriptions, it is important to have a PBM that already has systems in place to quickly and fairly assess specialty drug prescriptions, as well as to ensure compliance and adherence to help maximize the benefit to the patient using the specialty drug.

You can reach Spectrum Pharmacy Solutions at any time of day or night by contacting us through our 24/7 online customer support chat or by calling 1-8SPECTRUM4 (877.328.7864).