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August 31, 2021
Like the groups we serve, we’re relentlessly focused on the impact specialty drugs have on members’ total cost of care. Based on data from January to July 2021 across our family of health plans, specialty drugs made up only 1.2% of our total prescriptions across all lines of business, but they were over 53% of our allowed cost. This is consistent with recent previous years.
The Federal Drug Administration (FDA) also approves dozens of novel drugs for targeted treatments with price tags in the thousands or even millions of dollars. In 2021, 18 of these treatments were approved, with another 36 projected by end of year. These approvals make our clinical evaluation and management tools more critical than ever for ensuring appropriate utilization.
Specialty drugs treat complex, often chronic conditions and require clinical monitoring for safety and effectiveness. They’re costly and often need special handling, requiring patients to receive additional administration and disease management training. For those reasons, specialty drugs covered under the pharmacy benefit are dispensed by a specialty pharmacy with staff trained to provide support.
We take stewardship of groups’ and members’ health care dollars seriously. This includes developing innovative ways to improve care while reducing costs. Since specialty drugs can change and even save lives, we work hard to ensure our members have access to the care they need through cost-saving, innovative solutions. Below are a few examples:
Newly contracted specialty pharmacy provides valuable resources: In 2021 we smoothly transferred eligible members’ specialty prescriptions to Accredo, our new specialty pharmacy. Accredo provides clinical, operational and financial resources to ensure our members receive optimal care and support.
Coupon management programs deliver real savings: Pharmaceutical manufacturers commonly use drug coupons to reduce the cost of specialty medications for patients. These coupons, however, can unintentionally drive up costs by encouraging use of higher-cost medications. Coupon management programs, such as our Coupon Accumulator Adjustment Program and Coupon Copay Maximization Program, can help reduce the impact of prices on employers and members. The Coupon Accumulator Adjustment Program ensures a coupon’s value won’t be applied to the member’s cost accumulators; at the same time, the Coupon Copay Maximization Program allows the employer to take full advantage of the manufacturer coupon value—reducing costs for both the employer and the member.
For example, under the Copay Maximization Program, a manufacturer’s coupon valued at $10,000 per year enables an employer to redeem the full $10,000 value over the year—with $0 out-of-pocket expense for the member. We implemented this program for non-high-deductible health plans in 2021, **resulting in cost savings averaging $700 to $850 per medication fill for participating employers, ** depending on the drug and the coupon offered. The program’s list of qualifying medications is set to double in 2022 due to our partnership with Accredo.
Split-fill program lowers health care costs: Members who start treatment using high-cost medications with a high risk for intolerance or required dosage change within the first several months of treatment can receive a two-week supply for half of their monthly copay amount. Currently, we provide this cost- and waste-reducing program to members on certain oral drugs for the treatment of cancer. **Early results of our oncology program across our family of health plans show as much as $88,000 in quarterly savings for the health care system. **
Channel management and the pharmacy benefit can deliver significant savings annually: Shifting medication coverage from the medical to the pharmacy benefit can save money—both for the individual and employer. That’s because there’s better contracting and utilization management under the pharmacy benefit. In 2020 we implemented channel management for hemophilia products, which has delivered savings of over $0.40 PMPM across all lines of business. Members can now conveniently receive their hemophilia products through the specialty pharmacy.
We continue to explore other opportunities to implement channel management strategies, particularly for medications like Nucala and Xolair, which can be given either via infusion or as a self-administered injection. In a pilot program, we’re working with members and prescribers to move members to less-expensive, self-administered options that are dispensed through specialty pharmacies. **Moving one member to the self-administered version can save nearly $25,000 a year for the employer and cut costs for the member. **
Network management: Layered atop our channel management work, we also guide members to receive care from in-network providers to improve care and reduce costs for both them and their employers. In 2021 we launched a select hemophilia network that combines our specialty pharmacy and contracted hemophilia treatment centers. This ensures improved savings through contract rates (ranging from 0.5% to 7%) with facilities and specialized care for members. We’re expanding network management in 2022 to other areas of specialized care, such as cystic fibrosis.
There’s no one-size-fits-all strategy to manage specialty drugs’ increasing cost impact. While continuing to monitor pharmaceutical products coming to market, we’re also exploring both broad and targeted solutions for specialty drugs. Next month in Producer News we’ll provide insight into our innovative oncology drug management programs.
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