Medical Benefit Management for Specialty Rx

Oct 3, 2013
Medical Benefit Management helps rein in specialty drug spending and provides care and services tailored to patients, ensuring safety and healthy outcomes.

It’s no secret: Specialty medications, for patients with complex, chronic conditions, are expensive. For most plans, fewer than 1% of members use specialty medications, and yet they account for 38% of total drug spending. Specialty patients also require the most personalized care and counseling because of complex medication regimens and the unique needs of each patient.

Express Scripts, through its subsidiary Care Continuum, offers a solution that meets the needs of both plan sponsors and patients while reducing the administrative burden on physicians.

Plan sponsors using our Medical Benefit Management services have, on average, saved 10% to 15% on their specialty spending.

The Issue

Spending on specialty medications is expected to increase approximately 20% annually for the next several years, compared to less than 3% for traditional medications. By 2015, specialty medications are expected to reach 49% of total spending on prescription drugs.

Nearly half of all specialty medications are currently billed through the medical benefit, which lacks the aggressive cost-control strategies and oversight of the pharmacy benefit. Express Scripts and its subsidiaries, including Accredo, offer the industry’s widest range of tools for managing the cost and administration of specialty drugs billed under the medical benefit.

Medical Benefit Management

For payers, tools that span both the medical and pharmacy benefit can help rein in specialty drug spending. For patients, this approach provides care and services tailored to their unique needs. It also helps physicians ensure patient safety and health outcomes.

Value of medical benefit management

Benefit to Plan Sponsors

Our wide range of trend management programs enables greater oversight of specialty drug spending. We optimize the channel and use of specialty medications through network and utilization management, and our medical benefit management services control spending for specialty medications billed through the medical benefit.

Our MBM services are available across conditions, sites of care and disease states. They include:

  • Utilization Management: Ensures the safe and appropriate use of specialty drugs billed through the medical benefit
  • Site of Care Management: Redirects patients and medications to the most clinically appropriate and lowest-cost channel
  • Reimbursement Management: Verifies that claims are paid accurately and at the contracted rate,  and improves rebate opportunities
  • Oncology Decision Support: Drives cost-effectiveness and quality care by encouraging clinical decision-making using evidence-based guidelines
  • Medical Channel Management: Allows plan sponsors to exclude specific specialty drugs from the medical benefit, covering them exclusively within the pharmacy benefit where appropriate

Benefit to Patients

Living with and managing a specialty condition can be difficult and stressful.  We do everything we can to make it simple. Our team of disease-specific specialists can tailor clinical counseling to each individual patient’s needs. As a result, patients are more adherent to their therapy and achieve healthier outcomes.

Our clinicians are trained in complex conditions and can answer any questions about the condition, medications used to treat it, potential interactions and any possible side effects. Pharmacists are available 24 hours a day.

Accredo also offers the industry’s widest access to limited-distribution and exclusive-distribution drugs, ensuring consistency of care for patients.

Benefit to Physicians

ExpressPAth® is our award-winning, web-based provider portal designed to reduce administrative demands on physician offices. Through ExpressPAth, providers can manage specialty drugs dispensed through the medical benefit and check patient eligibility and benefits in real time. Starting next year, physician offices also will be able to manage prior authorizations for both pharmacy and medical benefits. This tool helps ensure that patients receive their medications faster and that office staff spends less time phoning and faxing the health plan. It allows providers and their office staff to receive real-time prior authorization with ExpressPAth if their responses meet the plan sponsors’ clinical criteria.

Author Bio

Lab Staff
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