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Specialty Drug Prices- Why the Jumps? Can we do anything about it?
Nayda M. Rivera, RPh., MBA Government & Industry Partnership Director
abarca health
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Specialty Drugs • Specialty drugs target conditions that affect smaller patient
populations so costs are spread out over less individuals
• Used to treat more than 100 life-threatening diseases and complex chronic conditions that previously had no therapeutic options
• Very effective in decreasing debilitating effects of a disease • New specialty drugs approved in 2015
• Orphan indications
• Cancer • New Hep C therapies • PCSK9 for high cholesterol
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Specialty Drugs Trends • <1% pts use specialty drugs, but they represents 32% or
more of drug spend • Approximately one-third of drugs in the future pipeline will
be delivered in an oral tablet form • Specialty drugs for treating conditions such as rheumatoid
arthritis, multiple sclerosis and cancers will continue to make up approximately two-thirds of drug spend within the pharmacy benefit over the several years
• Specialty drugs will become the main driver of overall health care benefit cost trends
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GHIP 2015 Plan Paid in some Specialty categories
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Priority of goals in managing specialty drugs
1. Reduce inappropriate utilization 2. Improve adherence/compliance 3. Reduce drug acquisition costs 4. Reduce variability between the
pharmacy and medical plan design 5. Improve productivity
Copyright © 2014 MBGH
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– PA/ ST – QL – Partial first fill for specialty drugs, like oncology
Improve Adherence and Compliance – DUR – MTM Programs
Specialty Drugs: Reduce Inappropriate Utilization
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Specialty Drugs:
Reduce Drug Acquisition cost Pharmacy contracting: Specialty Drugs aggresive discounts
– Open Pharmacy Network – Narrow Pharmacy Network – Preferred and Non Preferred Network
Coordination of benefits: plan responsibility
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Aggresive rebates negotiation with pharmaceutical companies: • Base rebates for formulary access
– Exclusive vs Parity • Risk Based Rebates (outcomes) • Rebates on all claims • Strategies to control impact of price increases • Additional Specialty Tiers • Patient co-pay or co-insurance
Specialty Drugs:
Reduce Drug Acquisition cost
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Improve Productivity • Management of Related Chronic Conditions • Medication Adherence • Treatment Compliance • Increase in Productivity • Reduction of Abseenteeism • Increase Quality of Life
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There is a tsunami in the distance called the specialty drug pipeline and those who do not
prepare now will suffer great losses
Doing nothing is no longer an option
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