Medical Benefit Specialty Drug Management–A Call to Action

Benefit Design
For medical benefit specialty drugs, benefit design includes patient out-of-pocket costs and whether specialty drugs are covered exclusively under the medical benefit, or under both medical and pharmacy benefit. Ideally, payers and plan sponsors should be able to provide or receive integrated clinical and financial data for specialty drugs, regardless of benefit design. One way to strategically achieve this is to have a single source managing all prior authorizations, regardless of benefit design, triaging to the most cost-effective site of service, matching claims to authorizations, and finally, offering in close to real-time, transparent, integrated clinical and financial data.

The Value of Effective Medical Benefit Drug Management
A recently released white paper4 expressing payer and plan sponsor insight into the value of an effective medical benefit drug management program highlights examples of best practices:
  • Control of spending from a clinically-based partner with evidence-based experiences.
  • Alignment of appropriate, transparent, nationally recognized, evidence-based guidelines, dose checks, and competent clinic dialogue.
  • Evidence-based insights through the combination of good, measurable outcomes, and integration with the most up-to-date peer-reviewed clinical data.
  • Efficiency in benefit design, provider capabilities, and identification of providers who significantly deviate from transparently developed “best practice” metrics.
  • Meaningful collaborative clinical support that recognizes unique patient characteristics.
  • Administered utilization management that mirrors physician, clinical, and operational workflow, while minimizing management burdens. 
Key Elements for Successful Medical Benefit Drug Management
  • Actively practicing credentialed clinicians, ideally physician specialists or subspecialists, to provide peer-to-peer interventions that incorporate the latest nationally accepted evidence- based medicine.
  • Objective site-of-service management, ideally free from the revenue conflicts of drug dispensing.
  • Integrating relevant clinical data with financial data that ensures concordance to evidence-based medicine, while reducing waste.
  • Availability of near real-time transparent and actionable data.
  • Improving the quality of care while reducing specialty drug trend.
  • Prior authorization mechanism that minimizes administrative burdens while, fitting within physician clinical and operational workflows. 
Can PBMs or Specialty Pharmacies Play a Role in Medical Benefit Drug Management?
The short answer is yes, but only with the right set of tools and the right mindset, that collaboratively working with providers is a necessary element for success.

“In this era of rapidly evolving drug therapies, inclusion of practicing subspecialists is a key element to any effective medical or drug benefit management process,” said Anthony Lam, MD, chief medical officer at PharMedQuest. “They can best identify cost-saving opportunities that do not compromise patient care, while maximizing physician buy-in through meaningful and collegial peer-to-peer interactions at the subspecialist level.”

The new presidential administration will likely have significant impact on the future of the Affordable Care Act. Clearly, what is currently needed by payers and plan sponsors is an effective prior authorization mechanism that addresses specialty spend under the medical benefit, which is also provider-friendly, and ensures that high-quality, cost-effective drug therapy measures for rare and complex diseases are being followed.

  1. PBMI 2016 Specialty Drug Benefit Report
  2. EMD Serono Specialty Digest – 12th Edition
  3. Access Market Intelligence Whitepaper, Bend the Curve, A New Era for the Management of Specialty Pharmaceuticals (
  4. Community Oncology – March/April 2005 – Dawn Holcombe
  5. MedPac – November 12, 2014
  6. Avalere Whitepaper – Total Cost of Cancer Care by Site of Service – March 2012
  7. Casolino LP, Nicholson S., Gans DN, et al.  What does it cost physician practices to interact with health insurance plans?  Health Aff (Millwood) 2009;28 (4); w533-43

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