Does Your Specialty Rx Management Program Address Half Of Specialty Spend – Part 2

Questions you should ask to assess the robustness of your medical benefit specialty drug management program

This is part two of two-part series on specialty drug management and spend.  You can find the first post in the series here. 

What questions should you ask of your medical carrier to assess the robustness of your medical benefit specialty drug management program?

Now that you understand the differences between pharmacy and medical benefit drug claims. It is time to assess the robustness of your medical benefit specialty drug program. There are 10 key questions you need to ask:

1. What utilization management and claims edits are in place to ensure accuracy of medical benefit drug claims pricing?
2. How are specialty medications processed under the medical benefit? For example, are HCPCS or NDC-11 drug identifiers and quantities required on all medical benefit drug claims?
3. Is there a formulary with product preferencing inclusive of biosimilars under the medical benefit?
4. Is prior authorization or step therapy in place for medical benefit drugs? Is this coordinated with the prescription drug plan?
5. Is there a process in place to use the least restrictive, most cost-effective site of care? Is this part of the initial prior authorization review process?
6. Are programs in place to leverage copayment maximizers, pharmaceutical manufacturers, or other foundation assistance programs to help offset patient and plan costs?
7. Are rebates collected based on my plan’s utilization, and how are these rebates passed back to my plan?
8. What other targeted strategies are in place to manage utilization and address waste?
9. What care and case management programs are in place for patients utilizing specialty drugs under the medical benefit? How do these programs impact quality, outcomes, and total cost of care?
10. What is my plan’s medical specialty drug cost and trend and how have your programs helped to manage the trend?

Do you feel you are able to assess the robustness of your medical benefit specialty drug management program? Now is a great time to talk with us and let us help you make sure that your specialty drug management program addresses 100% of your specialty spend, regardless of pharmacy or medical benefit coverage.