Publish Date: March 6, 2023
Author: Thomas Zimmerman
Tags: Blog - SeubertU

Addressing Ongoing and Upcoming Trends in Specialty Medication Benefits

Provided by Thomas Zimmerman III, CEBS

Specialty medications, also known as specialty drugs, are a class of prescription medications that are used to treat complex, chronic, or rare medical conditions. These medications are often expensive and require specialized delivery methods, such as injections or infusions, which can make them difficult to access and administer. In recent years, the use of specialty medications has increased dramatically, and this trend has had a significant impact on employer healthcare costs.   

One of the key drivers of the increased use of specialty medications is the aging population. As people live longer, they are more likely to develop chronic and complex medical conditions that require specialized treatments. In addition, advances in medical research have led to the development of new medications that can effectively treat these conditions, but they come with a high price tag. For example, the cost of some cancer medications can be over $100,000 per year, and other upcoming medications in the FDA pipeline are expected to cost over $1,000,000.

The increased use of specialty medications has led to a significant impact on employer healthcare costs. These medications often come with high price tags, which can drive up the cost of health insurance for employers. In addition, the complex delivery methods required for specialty medications, such as injections and infusions, can add additional costs for employers, such as the cost of specialized medical equipment and the cost of administering these treatments. The physical location where a specialty medication is delivered and whether the treatment is processed as a medical or pharmacy claim result drastically different costs. Introduction of programs designed to encourage or require administration of specialty medications at the lowest cost, medically appropriate site of care can make a significant financial impact.

The impact of specialty medications on employer healthcare costs is particularly significant for self-insured employers. Self-insured employers are responsible for covering the cost of their employees’ healthcare, and this includes the cost of prescription medications. When the cost of specialty medications is high, it can be difficult for self-insured employers to manage these costs and keep healthcare premiums affordable for their employees. Employers sponsoring self-insured health plans are likely familiar with Stop Loss protection. In recent years, pharmacy benefit managers have started introducing Stop Loss pools specific to high-cost medications that aim to provide additional protection complimentary to traditional Stop Loss and protect claims experience and renewal costs.

Additional strategies to consider include increasing access to generic medications and biosimilars, which are similar to specialty drugs but are not identical. Benefit plans designed to encourage use of these FDA approved alternatives could also help to reduce the cost of specialty medications. Generic medications and biosimilars are often much less expensive than their brand-name counterparts, and increasing the availability of these medications could help to reduce costs for employers and their employees.

Finally, implementing effective disease management programs could also help to address the impact of specialty medications on employer healthcare costs. Disease management programs are designed to help patients with chronic conditions, such as cancer or multiple sclerosis, manage their conditions more effectively. By providing education and support to patients, these programs can help to reduce the need for expensive specialty medications and other healthcare services.

In conclusion, the increased use of specialty medications is a significant trend that is impacting employer healthcare costs. To address this issue, it will be important to explore potential solutions that increase transparency in drug pricing, explore alternative payment models, increase access to generic medications and biosimilars, and implement disease management programs. By working together to address the impact of specialty medications on employer healthcare costs, we can help to ensure that employees have access to the medications they need to manage their health conditions while also keeping healthcare costs affordable. 

Contact our risk consultants today to learn how these strategies can minimize your business’s Rx costs.