Cover expensive specialty drugs without breaking the bank


Specialty drugs have left insurers in a bit of a predicament. The companies want to provide access to these efficient and effective medications for treating chronic conditions like cancer, arthritis and multiple sclerosis, but they must temper the skyrocketing costs.

I've witnessed first hand the positive affect specialty drugs--which are structurally complex, require special handling or delivery mechanisms and cost more than other drugs--can have on treating cancer. My close friend's husband was diagnosed with cancer two years ago and underwent an intense treatment regime where he visited the hospital each day to receive an IV of specialty drugs.

Although his cancer wasn't detected until it was in the third stage and doctors were admittedly unsure how he would fare with the illness, the specialty drugs essentially saved my friend's husband's life. That's the encouraging side of the story.

Then we have the insurer side, filled with uncertainty and concern about paying for these life-saving medications. Last year, specialty drugs made up 25 percent of the $263.3 billion spent on prescription drugs.

"Spending on specialty drugs represents an increasing share of U.S. prescription drug spending and is growing at a rapid and unsustainable rate," America's Health Insurance Plans said in an issue brief released Wednesday. In fact, some specialty drug treatment regimens can cost upwards of $750,000 a year, AHIP noted.

So what can insurers do? AHIP highlighted several innovative steps health plans have taken to control costs, including:

Integrating pharmacy and medical benefits: Insurers have been covering specialty drugs through medical benefits, but that interferes with their ability to incorporate cost-sharing methods. Integrating the medications into their pharmacy benefits could help by recognizing the uniqueness of specialty drugs while allowing for appropriate tiers and coinsurance rates. With the integration of pharmacy and medical benefits, insures can track members' use of specialty medications.

Writing policies for adherence: Medication adherence is a priority for all types of drugs, and specialty drugs are no exception. Some insurers help members take their meds by engaging them about their illnesses. Other insurers are partnering with providers to explain medication guidelines and reach out to members with reminders to follow medication instructions.

Contracting with specialty pharmacies: To lower the cost of specialty drugs, insurers can contract with specialty pharmacies that coordinate delivery and treatment processes for the medication, which is often a complicated and intricate process. "These pharmacies are better suited than traditional pharmacies to monitor and track the use of specialty drugs and have the necessary training and expertise to handle their distribution," AHIP said in the brief.

I'm certainly thankful for any steps insurers can take toward making specialty drugs more widely available, particularly at lower costs. My friend still has her husband and her children still have their father. I've no doubt that similar stories of life-affirming gratitude exist throughout the country. May we continue to hear more. - Dina (@HealthPayer)