The growth of specialty pharmaceuticals brings with it significant challenges in navigating the complexities and additional challenges associated with plan coverage and reimbursement for this class of expensive treatments. While some plans are moving some classes of specialty drugs into pharmacy coverage, others remain outside the formulary and are relegated to medical coverage, presenting a number of tracking and reimbursement challenges to dispensing retail pharmacies.
By 2018, it is estimated that more than 50 percent of the drug spend in the U.S. will be on specialty drugs as more specialty treatments are developed.¹ The trend is driven primarily by emerging technology in biologic drug manufacturing, longer protection of patents for biologics and therapies that are “tailor-made” to match the patient genetic makeup.
Retail pharmacy economics have been highly challenging in recent years. Expiring patents for many of the biggest-selling brand drugs has had a dramatic impact on top-line revenue. Historically, expiring patents would have been great news for retailers, as generic drugs have long driven profits. However, profits have eroded in the face of increases in discount and free generic programs, aggressive MAC pricing, coupled with the recent rise in generic drug cost.
Specialty pharmacy presents opportunities for business diversification, as evidenced in the number of companies tapping the specialty market. However, it also presents challenges for traditional retailers and manufacturers. Many new drugs are released in limited drug distribution networks, and many health plans and other payers have created limited specialty pharmacy networks to help control specialty drug spend.
Benefit coverage of specialty drugs is also can be much more complex. Payers expect specialty pharmacy providers to help manage utilization of these drugs to minimize waste and ensure patients are benefitting from these expensive therapies. Coverage can be provided from the patient’s medical benefit rather than the pharmacy benefit, but that can result in investigations regarding benefits as well as billing and reconciliation challenges, all delaying reimbursement to the pharmacy. Benefit design and new specialty tiers come with a much higher patient co-pay or co-insurance, requiring pharmacies to be able to coordinate across multiple benefit plans, including patient assistance and co-pay assistance programs.
The complexity of the disease state, intense Risk Evaluation Mitigation Strategies programs, unique drug administration requirements, complex therapy regimens and drug toxicities have led pharmacy providers to implement complicated patient-support programs. These programs require extensive reporting back to the payer, the manufacturer and potentially FDA.
Managing the complexities of specialty drug business requires pharmacies to have the agility to identify and track exceptions, reconcile payments, and minimize sales outstanding. Inmar’s software-based solutions make that possible, with the ability to search and sort unreimbursed transactions by multiple categories, and generate accounts receivable aging reports that aid in the effort to maximize payment within specified timelines that meet your company’s objectives.
Inmar solutions can be tailored to accommodate your company’s business rules to automate processes and enable insight to create a more complete picture.
¹ Formulary, June 1, 2013.www.formularyjournal.com 6/24/2013For more information, call today at (866) 440-6917 or email firstname.lastname@example.org.