Specialty drugs are typically used to treat debilitating and life threatening medical conditions such as cancer, multiple sclerosis, rheumatoid arthritis and other diseases. Employers and health insurers trying to control pharmacy benefit costs are finding that specialty medications are outpacing all other costs. Expenditures on specialty medications are one of the fastest growing components of pharmacy benefits, and are projected to increase by 20% a year for the foreseeable future. At the same time, plan sponsors feel powerless to question or influence specialty therapy prescribing despite eye-popping prices charged by manufacturers.
Specialty pharmacy represents the greatest threat to pharmacy benefit solvency
Facts About Specialty Pharmaceuticals:
- The number of specialty medications has grown from 15 to over 300 since 1995.
- They account for 20% or more of annual spend on pharmaceuticals.
- They often cost over 50 times more than traditional drugs.
- They are critical to patient care.
- They treat complex and chronic conditions.
- They can cost thousands to hundreds of thousands of dollars per treatment.
The US-Rx Care Difference Provides Peace of Mind
- Separation of dispensing from the benefit management & prior authorization functions.
- Expert clinical oversight by independent, third party, fiduciary.
- Verification of medical necessity and appropriateness.
- Conformance to established guidelines and best practices.
- Counseling of physicians and patients to ensure proper use and administration.
- Elimination of prescriber buy and bill incentives for high cost therapies.
- Management of side effects to maximize patient adherence, particularly with self-administered medications.
- Prevention of waste and over shipping by dispensing pharmacies.
- Strictly-managed quantity limits.
- Utilization of cost effective therapies and step therapy, when appropriate.
A Track Record of Success
US-Rx Care offers clients an unparalleled track record of clinical management experience necessary to effectively curb plan costs for specialty pharmaceuticals. Our team of professionals has managed specialty pharmacy benefits covering over 2mm lives for more than 15 year’s time. We make sure that medications are being prescribed only to patients that will benefit from them. Our clinical professionals engage prescribing doctors at a peer level to choose the best possible drug therapies in each individual case based on clinical and cost effectiveness. No pharmacy benefit plan sponsor can afford to be without US-Rx Care’s Specialty Rx Management Program.
Specialty Rx Management Features and Benefits
- Regular communication with prescribing doctors and patients.
- Prevention of inappropriate and unnecessary prescribing.
- Enhanced quality of care.
- Immediate, measurable, and verifiable cost-savings.
- Independent, clinical expertise. No conflicts of interest.
- Very low cost per case and great return on investment for our clients.
This program is designed to review all specialty pharmaceuticals that cost more than $250 per dose. All pre-screening and prior authorization functions are performed by US-Rx Care’s clinical professionals.
Case Example 1: $19,844 savings to the plan
JO is a 61 yo male diagnosed with Psoriasis who has failed on Taclonex, Lidex and Dovonex. MD ordered Humira 40mg SQ qwk. US-Rx Care recommended a treatment trial with Methotrexate and to test patient for TB. MD agreed to a trial of Methotrexate and the TB test. JO was negative for TB and the Psoriasis responded well to methotrexate and topical corticosteroids.
Case Example 2: $13,392 savings to the plan
NS is a 30 yo female diagnosed with Hepatitis C (Genotype 2). MD ordered Pegasys 180mcg SQ qwk and Ribavirin 200mg x 2 BID for 48 weeks. US-Rx Care ensured that NS had sobriety from alcohol and recommended a 24 week treatment plan and not 48 weeks based on guidelines and the literature.
Case Example 3: $7,560 savings to the plan
AF is an 85 yo male with a history of chronic kidney failure and anemia. AF also has a history of coronary artery disease, and has fluid buildup in his arms and legs. AF was prescribed Procrit 20,000 units weekly for 6 weeks for end stage renal disease. A US-Rx Care clinician checked AF recent lab tests and noted that his iron levels were low (50.1ng/ml). Procrit does not work without proper iron stores in the body (>100ng/ml). In addition, the patient’s hemoglobin was normal at >11. Pharmacist recommended starting oral iron three times daily to raise and maintain iron levels at > 100ng/ml. Procrit was ultimately not needed for this patient.