Benefit Design Innovations to Manage Specialty Pharmaceuticals

BACKGROUND: Spending on specialty pharmaceuticals is rising faster thanthat for traditional drugs. In 2006, specialty drugs were the largest category driving drug costs and utilization trends. Even with effective management, expenditures on these agents are projected to increase exponentially in the coming years. OBJECTIVES: To review benefit design strategies used by payers to control costs and manage utilization of specialty pharmaceuticals. SUMMARY: The rapid growth in specialty pharmaceutical expenditures reflects the introduction of new agents, broader indications, and wider use in more common disease states. The true growth of the specialty pharmaceutical segment is obscured because many of these agents are reimbursed through the medical benefit, which often lacks the transparency necessary to accurately determine true cost and utilization trends. To date, efforts to control spending on biologics have been fragmented with most payers employing techniques for cost and utilization containment similar to those used for traditional pharmaceuticals. To ensure greater cost and utilization control, a benefit design that simultaneously provides optimal cost management, appropriate utilization, improved clinical management, enhanced clinical outcomes, and heightened patient safety should be established. CONCLUSIONS: Current management techniques for specialty pharmaceuticals often represent a stop-gap approach for controlling rising drug costs. Creation of a specialty pharmacy benefit can optimize cost and utilization management.