Three things can happen if you don’t effectively manage specialty drug costs across the pharmacy and medical benefit divide:
- Members will get confused. Specialty members often face different coverage policies depending on which benefit is used. This inconsistency is confusing. It can drive members to “benefit shop” as they look for the cheapest way to get medicines.
- It makes it harder to manage costs. A lack of detail in medical claims can make it hard to know the true costs of specialty drugs. Is the doctor charging for the whole vial of specialty drugs or just the portion required for that member’s infusion? Are product administration and patient monitoring fees part of the bill?
- Your efforts to promote efficient use will be hindered. Network and channel management are the best ways to control the cost and quality of care associated with specialty drugs. Inconsistent rules across benefits make it hard to be sure that the most cost-effective distribution channels are consistently used.
Prime applies proven pharmacy benefit management techniques on both sides of the benefit divide. We don’t manage medical and pharmacy benefits in a vacuum. Instead, we take a big picture perspective, choosing the best tools for each situation, regardless of where claims are paid or care is administered. This gives you a clear view of total specialty spending.