High Cost & Specialty Medication Cost Containment Services
Specialty drugs drive 40-50% of employer Rx cost but represent less than 5% of total prescription volume. The largest specialty pharmacies are owned by PBMs and a key driver for their earnings growth. It is wise to evaluate the effectiveness and appropriateness of clinical management for these high-cost medications.
Per the CBO, up to 80% of all drugs recently approved or under development could be classified as specialty drugs.
Prior Authorization Review Process
- AEC Rx delivers best in class prior authorization review through
- its regimented process
- Each PA is scrutinized by a clinical pharmacist from start to finish
- Pharmacists work collaboratively with prescribers leveraging their clinical • experience and latest clinical references each step of the way
- Pharmacy techs handle inquiries about clinical records, review status and • enter initial PA information in the system. They do not play a role in the • decision regarding a review
Focus on providing a thorough audit for all PAs rather than simply rubber stamping the PBM’s work - Disciplined review and audit occurs within each client’s specific turn-around time
- Vast majority of reviews completed within 48 hours, 24 hours for urgent reviews
PROCESS FLOW
- Claim Approved by PBM and Sent to AEC Rx
PHARMACY TECH
- Pulls review from PBM queue and enters it into AEC Rx processing system
SPECIALTY PHARMACIST
- Reviews the PA to verify:
- PA meets criteria
- Medication is on the formulary
- Any required steps were followed
- Medication is FDA approved
- Any off-label use is supported by clinical documentation
- All required tests were completed before prescribing
- Verifies dosage, weight, body mass, surface area
- Verifies quantity limits
- Determines if the medication can be managed to a clinically equivalent
- alternate, that is on the formulary and less expensive
PHARMACY TECH
- Enters completed review and any documentation into PBM queue for processing by PBM
“NEW TO MARKET” MEDICATIONS
Plan Sponsors are acutely aware of the increasing cost of providing critical prescription drug coverage to their employees. Part of this increase in cost is driven by the number of new medications coming to market. The FDA approved 48 novel drugs in 2019 and 53 in 2020 with the majority of these drugs classified as Specialty. Generally speaking, these “new to market” medications are more expensive alternatives to currently existing therapies. This trend will not abate.
FDA APPROVED
- 48 NOVEL DRUGS IN 2019
- 53 NOVEL DRUGS IN 2020