Health plans brace for specialty drugs eclipsing 50% of prescription spending

As more expensive specialty drugs, ranging from treatments for Alzheimer’s disease to new cancer drugs, hit the U.S. market, those who handle prescriptions and their claims are gearing up to focus even more on these expensive drugs.

Health plans and pharmaceutical benefit managers (PBMs) managing drug costs at this year’s Asembia Specialty Pharmacy Summit in Las Vegas say specialty drugs now account for 50% or more of total prescription spending they manage. In some cases, employer clients find that specialty costs represent 60% or even more of their total drug expenditures.

“It’s really scary for our customers,” Lucille Accetta, senior vice president of pharmacy benefit management and specialty product development at CVS Health, told hundreds of attendees at the Asembia event, which is taking place until Thursday and attracted more than 5,000 people from the health sector. . “We have to be the best buyer for our customers.

Executives from CVS, which owns major Caremark PBM and Aetna, the nation’s third-largest health insurer, as well as UnitedHealth Group’s OptumRx PBM, health insurer Humana and pharmacy giant Walgreens discussed the growing role pharmacy specializing in global drug costs at the Asembia meeting, which featured pharmacy executives from those companies on Tuesday morning.

The days when health plans and PBMs had to worry about the launch of a new cholesterol pill or prescription antidepressant that would cost $4 each and be taken by millions of Americans are long gone. . These days, it’s biotechnology-derived specialty drugs that may only represent 1% to 2% of the health plan claims process for an employer or government client, but are becoming a more important part what they have to administer and manage.

Last year, employer clients of major consulting firm Mercer averaged “specialty spending about 48% of total pharmacy costs based on calendar year 2021 data,” a spokesperson for Pharmacy said. the company.

To keep prescription drug costs under control while maintaining access to lifesaving treatments, health plans and pharmacies say they are monitoring patients more closely as soon as they take the drug, said Rina Shah, vice President of the Pharmacy Operations and Services Group at Walgreens.

Meanwhile, health plans say they are working closely with their customers, including employers, to provide them with options to cover not only ongoing prescription needs, but also gene therapies that will be of more prescribed in the future, said Michael Einodshofer, senior vice president and chief pharmacy officer. agent at OptumRx.

Health plan leaders say they are increasingly looking at “total patient health,” said Natalie Bedford, senior vice president of specialty pharmacy at Humana. This means the “physical, mental and social” aspects of the patient’s well-being, these executives said.

Other smaller, independent PBMs and health plans are also launching new products and platforms that they hope will help their government, commercial and employer customers better manage rising prescription drug costs.

Take Abarca Health, an independent PBM that manages more than $5 billion in drug costs annually for more than four million Americans, has leaders at this week’s Asembia meeting to talk about its efforts to better manage specialty pharmacy costs.

The company’s Assura solution launched earlier this year “guarantees the net cost of drugs, including specialty drugs, by providing a fixed annual cost per script for the entire population of a health plan,” said Abarca by announcing the new pricing solution earlier this year. According to Jason Borschow, CEO of Abarca, the guarantee is adjusted each year based on changes in drug coverage.

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