Moving specialty drugs to the pharmacy benefit would make the system more streamlined and removes an extra step from the process (having doctors and hospitals buy the drug and billing for it) which will help to keep costs down. A single benefit system would make coding for billing purposes a much easier process.
Are specialty drugs covered by my health plan?
Depending on the mode of administration, specialty drugs may be covered by a health plan as a medical benefit, pharmacy benefit, or both While Medicare is clear whether a drug is covered under the medical benefit or pharmacy benefit, commercial plans can vary in their benefit coverage decisions
What is a specialty drug?
Specialty drugs are used to treat complex and/or chronic conditions and may require special handling and administration Depending on the mode of administration, specialty drugs may be covered by a health plan as a medical benefit, pharmacy benefit, or both
Is a drug covered under Medicare or pharmacy benefits?
While Medicare is clear whether a drug is covered under the medical benefit or pharmacy benefit, commercial plans can vary in their benefit coverage decisions Medicare covers 80% of office-administered products under Part B.
Does Medicare cover all office-administered drugs?
While Medicare is clear whether a drug is covered under the medical benefit or pharmacy benefit, commercial plans can vary in their benefit coverage decisions Medicare covers 80% of office-administered products under Part B. If patients have supplemental insurance, their supplemental coverage may pick up the additional 20%
Why is specialty pharmacy important?
With specialty-trained pharmacists as part of the collaborative care team, enhanced patient satisfaction has been documented with fewer complications in drug treatment; improved laboratory monitoring; reductions in unnecessary medications; and shorter hospital stays resulting in lower treatment costs.
What is the difference between PBM and specialty pharmacy?
Like specialty pharmacies, PBMs fill prescriptions often via mail and offer specialty pharmacy services. In short, PBMs are generally larger organizations than specialty pharmacies with more complex organizational structures that focus on more than just providing specialty drugs.
What is a specialty pharmacy mandate?
A specialty pharmacy mandate is an insurer policy that requires beneficiaries to acquire and pay for some or all medical benefit drugs through a specialty pharmacy bypassing the traditional buy-and-bill model.
How are specialty drugs distributed?
In some instances, involving dispensation under the pharmacy benefit, specialty drugs are produced by specialty pharmaceutical manufacturers then sent to specialty distributors or large specialty pharmacies. From there, they may be distributed directly to patients or be sent to retail pharmacies.
How does a specialty pharmacy make money?
service revenue—Traditionally, specialty pharmacy revenue is derived from drug sales and rebates earned from PBM and manufacturers.
Are specialty pharmacies profitable?
The financial opportunity associated with hospital-owned specialty pharmacy is generally lucrative when the volume is present. It is not unheard of for 340B hospitals and health systems to generate 40% – 50% margins on their oncology specialty business.
Can Medicare patients use specialty pharmacy?
Specialty pharmacies focus on you and your individual health care needs. As a Medicare Part D member, with access to our large pharmacy network, you may fill your specialty medication at any pharmacy that is able to obtain the drug.
What service does the specialty pharmacy provide before dispensing of a specialty drug?
Specialty pharmacies provide services that include training in how to use these medications, comprehensive treatment assessment, patient monitoring, and frequent communication with caregivers and the patient's physician or other health care providers.
What is a specialty pharmacy and what are two examples of specialty pharmacies?
A specialty pharmacy is usually a subset of a larger health insurance provider, retail provider, or pharmacy benefit manager (PBM) that coordinates these services, although independent specialty pharmacies also exist. Some of the top Specialty Pharmacies in the U.S. include: CVS Caremark. Accredo.
How are specialty drugs different from traditional drugs?
What is the difference between a traditional drug and a specialty drug? Traditional drugs are used to treat general health and chronic conditions, such as flu, diabetes or a common infection. Specialty drugs may be used to treat complex and rare diseases, such as cancer, multiple sclerosis and rheumatoid arthritis.
Can a specialty pharmacy buy and bill?
The specialty pharmacy will bill the patient for their responsibility of the medication cost. (Note that the HCP may still bill the patient for office visit-related fees and/or product administration-related fees.)
What is a specialty pharmacy product?
Specialty pharmacies deal with medications not typically found in retail pharmacies. These medications are usually high-cost products used to treat complex diseases. This includes chronic and rare conditions. Oral, injectable and infused medications are dispensed and regular follow-up is provided.
What is the advantage of pharmatization?
Another advantage of what might be called the “pharmatization” of specialty drugs is the specificity of the National Drug Codes (NDC) used to make and pay claims when medications are under the pharmacy benefit.
Why are oncology drugs excluded from the study?
Oncology drugs, which many acknowledge are a world unto themselves because of the power of the provider group, the mortality of the disease, and other factors, were excluded from the analysis. Moreover, because infused drugs are more complicated to administer, the consultant presumed a 75% medical-to-pharmacy “conversion” instead of 90%.
Is moving medications to the pharmacy benefit?
Moving medications to the pharmacy benefit won’t win prizes for innovation or box-departing thinking. The fact is that it has been talked about for years. Patrick Gleason, PharmD, director of health outcomes for Prime Therapeutics, the Minnesota-based pharmacy benefit manager, says there have been fewer changes than all the talk might suggest: “It isn’t so simple. That’s why it hasn’t happened very much.”
Is Remicade a pharmacy benefit?
Infliximab (Remicade) tends to be paid for and managed as a medical benefit because it is infused, while adalimumab (Humira) and etanercept (Enbrel) tend to be managed as a pharmacy benefit because they are self-injected.
Can smart software solve the benefit divide?
Smart software can solve problems caused by the medical–pharmacy benefit divide, says Alan Lotvin, MD, of CVS Health. Perhaps all that is really needed is some well-designed software. That’s what Alan Lotvin, MD, thinks. “There is a solution,” says the executive vice president for specialty pharmacy at CVS Health.
What are specialty drugs?
Specialty drugs play an increasingly important role in the treatment of chronic conditions such as multiple sclerosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease and cancer, yet little is known regarding the comprehensive medical and pharmacy benefit utilization and cost trends for these conditions .
How much of specialty drug spending is medical?
With approximately 50% of the specialty drug spend occurring in the medical benefit and a variety of payment and dispensing options, it can be difficult for employers to get full transparency on specialty drug spending or overall utilization.
What is the strategy of a single benefits manager?
Strategy #1: Specialty drugs under one benefit. Regardless of which benefit covers the drug, a single benefits manager is responsible for evaluating the appropriateness of a therapy and its cost or value which addresses the need to obtain a more accurate picture of overall costs. Disadvantages/Limitations:
Advantages Of Moving Specialty Drugs To The Pharmacy Benefit
Does it make sense to move specialty drugs from medical to the pharmacy benefit? There are some advantages:
Good Reasons To Proceed Slowly
There are also good reasons not to simply make a blanket decision to switch all medications to the pharmacy benefit. Proceeding slowly, or making decisions on a case-by-case basis also has merits. In some instances, hospitals can buy medications at a lower price than specialty pharmacies because they can negotiate class-of-trade pricing.
Medical benefit
Medicare covers 80% of office-administered products under Part B. If patients have supplemental insurance, their supplemental coverage may pick up the additional 20%
Pharmacy benefit
References: 1. HealthInsurance.org. Accessed June 21, 2020. https://www.healthinsurance.org/glossary/specialty-drug 2. Medicare.gov. Accessed June 21, 2020. https://www.medicare.gov/coverage/prescription-drugs-outpatient 3. Kaiser Family Foundation. Accessed June 21, 2020. http://files.kff.org/attachment/issue-brief-an-overview-of-medicare 4.