Preparing Payers for the Next Wave of Specialty Therapies

In an interview at the Academy of Managed Care Pharmacy Nexus 2026 meeting, Katelyn B. Meyer, PharmD, clinical pharmacy manager at MassHealth, discussed how payers can prepare for emerging specialty therapies, a topic she will explore further tomorrow, October 28, as a panelist in "Ahead of the Curve: Emerging Specialty Therapies and Managed Care Readiness."

The session will examine how pipeline products in areas such as cell and gene therapy, rare diseases, and novel administration technologies present unique clinical, operational, and evidence-related considerations for managed care.

In this clip, Meyer noted that off-label coverage is a challenge across many drugs. Specialty treatments draw particular scrutiny, however, because they often address significant unmet needs and carry high costs that can make coverage outside their approved indications fiscally challenging for payers. The growth of cell and gene therapies has made these challenges more common, she said.

Meyer advised payers to identify the nearest qualified treatment center, particularly because state Medicaid programs without an in-state center must arrange single-case agreements, and patients may need to travel out of state for treatment. She also recommended that payers establish a plan to follow up with patients 1 to 2 years after approval to better understand their experiences and identify potential barriers, citing manufacturing challenges that have delayed treatment for MassHealth members.

Meyer distinguished true therapeutic advances, which improve overall survival, efficacy, or safety, from line extensions, such as oncology products reformulated with hyaluronidase for subcutaneous administration. These formulations can shorten a 4-hour infusion to roughly 10 minutes, but payers must consider whether the time saved represents meaningful value for the health care system, she said.

Looking ahead at the specialty pipeline, Meyer said she is watching oncology most closely, citing bispecific T-cell engagers, a personalized melanoma vaccine, and a major advance in pancreatic cancer. These developments come with substantial costs, as many therapies cost above $500,000 per patient. If such treatments reach large patient populations, their budget impact could exceed that of a $3 million gene therapy for a rare disease, she noted.

"Because there is such substantial progress in science in the oncology space, and we are moving towards curing more cancer, that's an area I'm watching, but also just because of the astronomical price tags and the downstream impact on payers like Medicaid," Meyer said.