Specialty Drug Prices- Why the Jumps? Can we do anything about it?

Nayda M. Rivera, RPh., MBA Government & Industry Partnership Director

abarca health

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

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

GHIP 2015 Plan Paid in some Specialty categories

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

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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

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

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

Improve Productivity •  Management of Related Chronic Conditions •  Medication Adherence •  Treatment Compliance •  Increase in Productivity •  Reduction of Abseenteeism •  Increase Quality of Life

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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