SPECIALTY DRUGS | FEATURE of price control and reduction. It is the PBM that sets the formulary – the medications in a certain category that will be stocked and accessible to the insured – and manages it to best effect. Depending on one’s industry, there are medications that might be appropriate to have within the formulary to best address the needs of the prospective patients. Self-insured payers need to communicate with their PBM to ensure that the formulary is being well managed and customized to meet the new demands of specialty drugs. PBMs can do even more to manage costly medication. They have contracts with national retail pharmacies and can thus negotiate for the greatest discounts on medications. Discounts can be achieved through PBMs by managing the uses of mail order prescriptions, too. Prescriptions by mail often come with added discounts and, as an additional benefit, can often improve medication adherence. It pays to review the practices of one’s PBM to ensure it is doing all it can to keep costs down. PBM’s have access to plenty of their own electronic data regarding prescriptions and usage within the plan, so make sure they are effectively reporting data to you, the payer.
Conclusion As healthcare continues to move toward more innovative and personalized approaches to care, specialty drugs will become the norm, not the exception. The skyrocketing cost of these medications is already part of the national debate. A long-term solution to this problem will need to balance profitability for the pharmaceutical company to fund their continued innovation with common sense protections against price gouging, more transparency in pharmaceutical pricing and a larger discussion about the true value these medications provide to the patient. Until then, the self-insured industry must continue to apply innovative solutions so patients can receive appropriate care at a price that won’t drive the payer to the poorhouse. ■ Dr. Bruce Roffe is a Pharmacist and President and CEO of HHC Group, a National Cost Containment Firm that services many self-insured employers throughout the United States located in Gaithersburg, Maryland. At one time, he was Assistant Director of Hospital Pharmacy at Detroit Receiving Hospital and University Health Center and was also an Adjunct Assistant Professor of Hospital Pharmacy at Wayne State University, College of Pharmacy and Health Sciences, Detroit, Michigan. He may be reached at broffe@hhcgroup.com. References Express Scripts “Super Spending: U.S. Trends in High-Costs Medication Use,” May 2015
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The Express Scripts Lab, “The 2014 Drug Trend Report,” March 2015
2
AARP Public Policy Institute PRIME Institute at the University of Minnesota), “Rx Price Watch Report: Trends in Retail Prices of Specialty Prescription Drugs Widely Used by Older Americans, 2006-2013,” by Leigh Purvis and Dr. Stephen Schondelmeyer, November 2015.
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Express Scripts “Super Spending: U.S. Trends in High-Costs Medication Use,” May 2015
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itunes.apple.com/us/app/prescription-saver/id503944589?mt=8
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www.goodrx.com
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April 2016 | The Self-Insurer
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