With nearly half of specialty spending occurring on the medical benefit in 2012, and seeing that specialty spending is predicted to account for 50% of total pharmacy spending by 2019, Mike Waterbury, president, ICORE Healthcare, specialty division of Magellan Pharmacy Solutions, reports that specialty drug costs will surpass traditional spending in the next few years.
With nearly half of specialty spending occurring on the medical benefit in 2012, and seeing that specialty spending is predicted to account for 50% of total pharmacy spend by 2019, Mike Waterbury, president, ICORE Healthcare, specialty division of Magellan Pharmacy Solutions, reports that specialty drug costs will surpass traditional spending in the next few years. Although the trend is well known to many employers, many are not prepared with management strategies that will deliver high-quality, cost-effective specialty care.
“Are you looking at the drug or the condition?” Mr Waterbury asked attendees. 90% of payers said they focused on specific drugs when asked if strategies focused more on specific drugs or cancer therapeutic category (such as breast cancer or lung cancer).
The 2013 Medical Pharmacy & Oncology Trend Report (www.icorehealthcare.com/icore-resources/trend-report.aspx) surveyed 48 top US commercial health plans that represent over 166 million lives. The report found that when implementing medical formulary, prior authorization was used in 76% of covered lives and physician reimbursement was used in about 54% of covered lives by payers.
Site of service was also found to be an ongoing and costly challenge. The survey respondents said that in 2013, 40% of all injectable medications were administered to their plan members in their provider’s offices and submitted for reimbursement under the traditional buy-and-bill process. This was significantly higher than in previous years.
As for whether or not these payers intend to join accountable care organizations, one-third of survey respondents said they had implemented an ACO strategy. Currently, cancer centers do not appear to be a major focus of ACO initiatives.
Mr Waterbury said that “Managing medical pharmacy spend demands a smarter approach.” He suggested that payers need the right tools to complement their strategies. These include:
The Push for Fair Pricing and Reform in Pharmacy Benefit Management
April 3rd 2025Amid growing legislative pressures and industry debates, pharmacy benefit managers (PBMs) are exploring new strategies to enhance transparency, reduce patient costs, and navigate the evolving healthcare landscape.
Read More
The Importance of Examining and Preventing Atrial Fibrillation
August 29th 2023At this year’s American Society for Preventive Cardiology Congress on CVD Prevention, Emelia J. Benjamin, MD, ScM, delivered the Honorary Fellow Award Lecture, “The Imperative to Focus on the Prevention of Atrial Fibrillation,” as the recipient of this year’s Honorary Fellow of the American Society for Preventive Cardiology award.
Listen
Using AI-Driven Strategies to Optimize Specialty Drug Costs, Manage Polypharmacy
April 2nd 2025As health care costs continue to rise, artificial intelligence (AI)-driven solutions are emerging as a powerful tool for managing specialty drug spending and polypharmacy risks, as showcased in recent research presented at the Academy of Managed Care Pharmacy 2025 conference.
Read More
Promoting Equity in Public Health: Policy, Investment, and Community Engagement Solutions
June 28th 2022On this episode of Managed Care Cast, we speak with Georges C. Benjamin, MD, executive director of the American Public Health Association, on the core takeaways of his keynote session at AHIP 2022 on public health policy and other solutions to promote equitable health and well-being.
Listen
How Recent Federal Policy Changes Are Shaping Managed Care Pharmacy
April 2nd 2025Federal legislative and regulatory changes are reshaping pharmacy practice, with key challenges in government funding, pharmacy benefit manager reform, and health care policy shifts—topics explored by experts at the Academy of Managed Care Pharmacy's annual meeting.
Read More
The IRA’s Unintended Consequences for Drug Pricing and Coverage
April 2nd 2025The Inflation Reduction Act (IRA) may be restricting Medicare Part D formularies, increasing patient costs, and stifling pharmaceutical innovation, experts warned at the Academy of Managed Care Pharmacy 2025 annual meeting.
Read More