Optimizing Specialty Pharma Product Access and Reimbursement Support Services

Published Online:June 23, 2014
Jeffrey Albright, director national accounts, Jazz Pharmaceuticals, said that many patients’ access to specialty pharmaceutical products—which treat serious or life-threatening illnesses—can be limited as health plans struggle to control costs. He provided important insight into pharmaceutical manufacturers’ strategies that aim to optimize appropriate patient access to the medications and products they need through various services that can provide reimbursement support.

Mr Albright began by describing the specialty drug landscape. Managing specialty drug costs is a strategic priority for payers. In 2012, specialty drugs accounted for more than a quarter of the total prescription drug spend, and over half of the $7 billion spent on drugs launched in 2012. Seven of the 10 top-selling drugs to be launched within the next 4 years are expected to be classified as specialty. By 2016, pharmacy drug spend is expected to reach $192 billion, and a sky-high total of $400 billion by 2020.

To control costs, payers are implementing a variety of practices. Some include cost-sharing for premiums or deductibles, limiting coupon use, integrating medical with pharmacy benefits, and implementing programs which educate patients and encourage appropriate medication adherence. However, if current premium rate increase trends continue, over 50% of formularies could have co-insurance by 2018. Mr Albright noted that very few patients can afford a 30% coinsurance on a $1,000 per month specialty drug. He said for the patient, “it becomes unstainable.”

Even with coupon or reimbursement programs, payers are pushing back. Most products now offer coupons, with 75% of patients using coupons for tier 3 drugs. Many payers argue that copay coupons circumvent their management abilities and increase their costs. Mr Albright provided UnitedHealthcare as one example of an insurer that has recently pushed back. In January 2014 they stopped covering 25 drugs which included Lipitor, and in July 2014 they are planning to stop covering several primary care drugs. By doing this, they avoid the cost losses associated with drug coupons. If they don't cover it, they don't have to accept the coupons. Still,  Mr Albright noted that while UnitedHealthcare said in March 2014 it would no longer accept coupons, it reversed its decision by April. He suspects there will eventually be a larger movement where other insurers do stop accepting coupons.

Mr Albright suggested that despite these trends, there may be alternatives to managing specialty drug costs. Employers, for instance, believe wellness programs and consumer-driven health plans are the most effective ways to contain costs. Manufacturers and payers may focus on specialty pharmacy services which can include individualized patient education, proactive intervention for medication adherence, and utilizing/sharing patient data across integrated technology networks.

“If we can get involved with some of these things, I think that this is a potential way of the future," said Mr Albright. "We can partner with payers where we’re not just bringing them a rebate check, we’re not just differentiating our product on price, but we’re differentiating our product based on a broader range of items."