The Issue
When reviewing claim utilization data with one of our large clients, due to a high medical plan premium increase, we discovered that the cost of specialty drugs accounted for nearly half of their drug claim utilization, even though they were attributable to only 12 employees out of the company’s 478 employees.
Our Solution
Specialty drugs are often biologics (drugs derived from living cells) that are high-cost, highly complex and often times, high touch (injected or infused). They are often used to deal with difficult conditions like cancer, multiple sclerosis, rheumatoid arthritis, psoriasis, etc. and typically require special handling, administration and monitoring. Although such treatment programs can be highly successful, cost controls are necessary to assure proper use of the drugs. We developed an aggressive utilization management program, requiring any specialty drug claimants to:
- 1. Obtain prior authorization when a specialty drug is ordered by a provider,
- 2. Follow a step therapy program, and
- 3. Adhere to certain quantity limits.
The Result
After one year, the specialty drug utilization management program produced a significant reduction in specialty drug claim costs, saving the company over $128,000.
Contact us to discuss whether implementation of a specialty drug management program can work for your company!