Specialty Drug Tool Box Spotlight: Clinical Review and Management

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As we move forward with our proprietary Specialty Drug Tool Box, we come to the third stage known as clinical review and management. Now that you have decided which specialty drugs you will include in your pharmacy benefit plan, have agreed on competitive and auditable discounts, analyzed and chosen appropriate dispensing channel options for various high cost specialty drugs, it is time to look at your plan from a clinical perspective. You must be certain that the specialty pharmacy chosen has optimal, detailed, current and updated clinical criteria; a well established formulary; and a robust utilization management program for all high cost specialty drugs.

This stage focuses on your plan's benefit design and looks at various clinical analyses and their ability to produce higher savings than just a discount on the cost. As you search for the best solutions, keep in mind that the co-pays for preferred, non preferred and biosimilar/generic drugs should always coincide with the analyses on efficacy, drug costs and rebates. Additionally, due to the sometimes toxic side effects, complex dosing and cost of specialty drugs, it is also imperative that the disease itself is managed, in addition to managing the drug that is prescribed to effect a positive and optimal cost health care outcome.

As you work with your PBM to decide which solutions will be the most effective for your budget and the population of people you plan to provide benefits for, consider the following:

1. Has your PBM worked with you to model and report different clinical programs and interventions and the associated savings? 
2. Has your PBM shared their specialty drug prior authorization criteria to be certain that it is detailed, evidence based, robust and current?

If you feel like these topics have not been covered, we recommend asking your PBM to dig deeper into their analysis so that you can be sure you have found the best solution for your pharmacy benefit plan.

Do you need help managing the growing high costs of specialty drugs in your pharmacy benefit? Contact PBIRx today! Our mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, visit us at www.pbirx.com or give us a call at (888) 797-2479 today!