Volume 1, 2017

What's So Special About Specialty Pharmacy?

Specialty Pharmacy

"You have Crohn's disease." Your mind races with a million questions—what is Crohn's? How do I manage it? What is a "specialty" medication and why do I need it? Is it covered under my benefits plan? Where do I even start??

Being diagnosed with a disease—any disease—can be scary. Throw in a type of medication you've never heard of and your anxiety goes through the roof. So, exactly what is a specialty medication? Specialty medications are often targeted therapies or biologics used to treat chronic, rare or complex conditions that typically cost more than traditional medications—a LOT more. In fact, in 2016, specialty medications accounted for approximately 42 percent of all drug spend [QuintilesIMS 2017]. By 2018, that number is anticipated to leap to 50 percent. This trend will continue to grow each year as the majority of the drugs in the pipeline are classified as specialty medications.

With the rising costs of specialty medications, plan designs are becoming more complex as different management strategies are implemented. This makes a complicated system even more challenging and confusing to both members and providers.

With Quantum Health's Specialty Pharmacy approach, we educate our members on their benefit design and help them to make the best choice for them AND their plan.

We also assist providers in navigating complex specialty pharmacy benefit designs. Many specialty medications, such as oncology and infusion medications, fall under medical benefits and require precertification. Quantum Health provides precertification services and evaluates the treatment site of targeted medications to ensure the member is receiving the best price for their procedure. For example, a Remicade infusion used to treat Crohn's disease may cost $10K per infusion if given at an outpatient hospital setting, but could cost $5-6K if provided by the specialty pharmacy or administered by a home infusion provider.

Another example of significant cost savings is about a member who was receiving intravenous immune globulin (IVIG) infusions at an outpatient infusion center for chronic inflammatory demyelinating polyneuropathy (CDIP) at a cost to the member of approximately $30,000 per month. When it came time to renew the precertification, the Quantum Health nurse talked to the ordering physician about moving the site of service to the member's home. The provider was agreeable to this change, so we contacted a preferred infusion company available through our member's network and assisted with setting the member up with home infusion. Not only did this site change make it more convenient for the member, it also provided him with a savings of approximately $280,000 per year.

Saving our members time, money and frustration is at the heart of what we do every single day.


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