Medical Channel Management for Specialty Rx

Aug 26, 2013
By adjudicating specialty Rx claims in the pharmacy benefit, Medical Channel Management allows plan sponsors to more actively control their specialty spend.

As plan sponsors grapple with the rapidly increasing costs of specialty medications, Express Scripts and our specialty pharmacy Accredo offer solutions to manage the growing trend.

Medical Channel Management is an approach to help plan sponsors gain better control of hidden costs that occur in the medical benefit. In fact, a recent Accredo study of six clients using Medical Channel Management demonstrated more than a million dollars in savings – an 8.4% cost reduction.

The Struggle to Control Costs

Our research shows that 47% of specialty spending is billed under the medical benefit. This makes it difficult for plan sponsors to control drug expenditures. In the absence of an effective Medical Channel Management strategy, most plan sponsors lack the program controls to eliminate unnecessary spending.

When specialty medications are billed through the medical benefit, plan sponsors face challenges such as:

  • Lack of cohesive drug health and safety oversight/coordination
  • Limited reporting and utilization management
  • Potential misalignment of physician financial incentives
  • Unintended migration of specialty costs to the medical benefit in response to pharmacy management programs

Benefits of medical channel management for specialty pharmacy

Medical Channel Management Delivers Value to Clients and Members

Medical Channel Management allows plan sponsors to exclude specific specialty drugs from the medical benefit and adjudicate these claims through the pharmacy benefit. Medical Channel Management provides the opportunity to proactively improve clinical and financial outcomes for both client and member:

Medical Channel Management does not disrupt medical care. It simply changes the way drugs are ordered and dispensed, giving plan sponsors the ability to more effectively manage the cost of specialty medications through:

  • Increased Visibility: Specialty pharmacy spending is tracked through the PBM, rather than a combination of PBM and medical
  • Uniform Utilization Management: Coverage of specialty medications is aligned with overall plan design
  • Therapy Management: Optimizing application of clinical guidelines, patient counseling, side-effect monitoring and waste management

Specialty drug spending will only increase as the population ages and, as noted in the chart below, more high-cost drugs come to market. Medical Channel Management can help lower these costs and provide greater protection for members.

Drugs in development therapeutic area

Author Bio

Lab Staff
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