Results of the EMD Serono Specialty Digest™, 10th Edition

Tampa—With spending on specialty pharmaceuticals increasing close to 20% per year and expected to account for half of all drug spending in the next few years, payers are implementing several initiatives to manage this category.

In the next 12 to 24 months, the most popular goals for specialty drug management include managing the drug cost trend, integrating specialty across the pharmacy and medical benefit, improving patient adherence, implementing shared risk payment reforms with providers, and aligning provider reimbursement across sites of care, according to the EMD Serono Specialty Digest^™, 10th edition.

Debbie Stern, RPh, president, Rxperts, Inc., presented the results at the AMCP specialty pharmacy meeting. Rxperts, Inc., a managed care consulting firm, developed the survey questions and all other content for the report. A 6-person editorial advisory board reviewed and approved the questions before publication.

Data were gathered in December 2013 via an online electronic survey from 91 health insurers that covered >124 million lives in commercial plans, Medicare Advantage, and managed Medicaid. Of the plans surveyed, 72 had commercial plans, 58 had Medicare Advantage, and 54 had managed Medicaid. Employees responsible for injectables and/or specialty drug-related services completed the surveys.

Although there is no consensus definition of specialty pharmaceuticals, 85% of plans said they were high-cost; 81% said they were for treating complex diseases and requiring special monitoring; 74% said they were for treating orphan, uncommon, and rare diseases; 73% said they required special handling, storage, and distribution; and 67% said they required limited distribution from manufacturers. Most of the plans defined “high-cost” as those costing between $600 and $1000 per month, according to Dr. Stern.

Of the commercial plans, 53% said they had specialty cost-share tiers. Of the plans with specialty cost-shares, 39% had copays, 61% had coinsurance, 42% had a single tier, and 58% had multiple tiers.

Furthermore, prior authorization was required for botulinum toxins in 88% of commercial plans, for intravenous rheumatoid arthritis medications in 85% of commercial plans, and for intravenous multiple sclerosis (MS) drugs in 78% of commercial plans.

In addition, 42% of the plans implemented a partial/split fill prescription program. The most common therapeutic categories included in partial/split fill prescription programs are oral oncology drugs (84% of programs), oral hepatitis C drugs (42% of programs), and oral MS drugs (24% of programs). In 55% of the plans, partial fills were limited for the first fill only. The top goals for partial/split fill programs were reducing waste/decreasing costs (100% of programs), improving adherence (63% of programs), managing side effects (63% of programs), reducing patient cost-share (29% of programs), and improving communication with patients (26% of programs).

The survey also found that 26% of plans had site of service management programs, while 38% said they planned on implementing site of service management programs in the next 12 months. The most common method plans said they direct patients to the preferred site of service were through prior authorization, recommended alternate site after a first infusion, and incentivizing with a lower cost-share.

In addition, 22% of plans had oncology clinical pathway programs, while 29% said they planned on implementing the programs in the next 12 months. Of the plans with clinical pathway programs, 52% used a third-party vendor to manage the programs, 50% collaborated with oncologists to develop pathways, 24% created proprietary pathways, and 17% relied on oncologists to develop pathways.