Medical Benefit Management Reins in Specialty Drug Spend

Apr 9, 2015
Express Scripts’ comprehensive Medical Benefit Management program offers better control for medically billed specialty drug spend, including associated drug administration services.

Plan sponsors everywhere are facing unsustainable increases in specialty drug spend.

Specialty medications for patients with complex, chronic conditions are vastly more expensive than traditional medications. For most plans, less than 1% of members use specialty medications, and yet they account for 38% or more of total drug spend.

Keeping Specialty Spend Under Control

Our data has proven to show that plans that implement Medical Benefit Management services have recovered up to 15% of their specialty spending each year.

In fact, one of our clients who has been working with Express Scripts to manage its medical benefit recently determined that they saved more than $10 million in drug spend over the past year as a result of using our Medical Benefit Management solution.

Realizing the Potential for Managing Spend

According to the Drug Trend Report, nearly half of all specialty medications are currently billed through the medical benefit, which lacks the visibility, cost-control strategies and oversight of the pharmacy benefit.

Spending on specialty medications is expected to increase approximately 20% annually for the next several years, while traditional drug spend will increase less than 3%.

This year, U.S. health plan sponsors are projected to waste more than $9 billion, or 49% of their total pharmacy spend on specialty medication services that provide no additional value. This wasteful spending could be recovered if payers applied the same cost-saving techniques from the pharmacy benefit on medications that are administered through the medical benefit.

Medical Benefit Management Reins in Specialty Drug Spend, Improves Health Outcomes

While plan sponsors recognize the urgent need for robust management of their medical benefit spend, they often lack the infrastructure to develop and support these necessary programs.  Express Scripts has been able to draw upon decades of drug management experience to build clinical utilization and claims management solutions applicable to the medical benefit.

An effective Medical Benefit Management program offers services across disease states and sites of care and consists of three key components:

  1. Utilization Management:  Specialty drugs billed under the medical benefit lack the clinical policies applied to drugs dispensed under the pharmacy benefit. Approximately 15% to 20% of drug requests billed through the medical benefit do not meet evidence-based treatment guidelines. Closing this gap can help save $1.3 billion annually and ensure patients are receiving clinically appropriate therapy.
  2. Site of Care Management:  Costs for Specialty medication billed under the medical benefit vary by site of care – for instance drugs administered in the outpatient setting are often significantly more expensive than at-home care. Site of care programs redirect patients and medications to the most clinically appropriate and lowest-cost channel and could save up to $1.7 billion a year.
  3. Reimbursement Management:  Having robust reimbursement management ensures that claims are paid accurately and at the contracted rate. Claims management tools could save payers $1.9 billion annually. These programs also can greatly improve the data available for health plan analysis and allow health plans the ability to receive rebates for drugs dispensed under the medical benefit.
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