Estimated Cost Savings Associated with the Transfer of Office-Administered Specialty Pharmaceuticals to a Specialty Pharmacy Provider in a Medical Injectable Drug Program

Abstract

C O N T E M P O R A R Y S U B J E C T• This MCO's solution to the clinical, financial, and operational challenges of managing office-administered specialty pharmaceuticals involved (a) the transfer of certain office-administered, nononcology medical injectable drugs (MIDs) from "buy and bill" physician reimbursement using HCPCS (J) codes to purchase from a single, exclusive SPP at discounted reimbursement rates based on National Drug Code (NDC) numbers, and (b) reduction in physician reimbursement for MIDs to the SPP rates for medical offices that opted to continue to use the buy-and-bill method.

The effect of a collaborative pharmacist–hospital care transition program on the likelihood of 30-day readmission

“…19,20 In particular, studies have found that medication counseling and reconciliation may reduce 30-day readmission rates. 14,21,22 Pharmacists are increasing their role in patient care interventions, [23][24][25][26][27] including care transition programs, 15,19,21 but more research is needed to assess the impact of such programs.…”

Health Plan Utilization and Costs of Specialty Drugs Within 4 Chronic Conditions

“…As shown in Figure 2, specific specialty management programs and policies include the following: (a) channel management that may result in narrowing the specialty drug pharmacy provider network to a limited number of dispensing pharmacies in order to obtain greater unit cost discounts; (b) contracting and rebates that may result in pharmaceutical manufacturer inflationary price protection and rebate optimization via formulary preferred product(s) steerage; (c) implementing utilization management or medical policy pre-authorization to prevent unsafe use or investigational use including requirements to try the preferred formulary product(s) prior to the nonpreferred product(s); and (d) coordination of care between the medical and pharmacy benefit clinical care teams, for example, disease management and specialty pharmacy care management. 7,[16][17][18][19] The goals of these programs include helping members understand and manage their conditions; providing guidance in using health care resources judiciously; maintaining or improving adherence to the member's care plan, including specialty drug therapy; and obtaining best pricing.…”

Opportunities and Challenges of Specialty Pharmaceuticals

“…Specialty management strategies include custom formularies and benefit designs, clinical utilization management, provider reimbursement contracts, fraud and billing error monitoring, and distribution channel management. [13][14][15] Formulary management of specialty products has been used by payers for many years, 16 and nearly 10% of the cost of self-administered specialty products can be avoided with a robust formulary optimization program. However, most of the distribution-related specialty savings for self-administered drugs have been extracted due to pervasive specialty pharmacy distribution contracting.…”