Specialty Medications - Life Changing But at a High Cost  

It’s an exciting time in the healthcare world. Since the early 2000s, technology,FDA Approved innovation and scientific discoveries have increased the number of available specialty medications. In fact, upwards of 30 new specialty medications are expected to hit the market in 2017.

Many of these new drugs treat rare and previously untreatable medical conditions, like Hepatitis C and certain cancers, and are life-changing for patients and their families. MedCost wants members who require these medications to safely and effectively utilize them to treat their medical condition. However, use of these drugs comes at a high cost—literally. Click here to see some of the most notable new drug approvals year-to-date and the average annual costs associated with them.

Biosimilars – Not the Same as Generics 

Discussions on high-cost specialty medications often bring up questions about generics and controlling costs. Generics of high-cost, injectable specialty medications are called biosimilars. Biosimilars are not generic equivalents of the original product and are more difficult to develop than other generic drugs. Manufacturers of injectable medications are faced with a sophisticated production process, comprehensive FDA approval requirements, and high costs. After the initial FDA approval, many manufacturers seek other medical uses for their products to prohibit others from copying their drug and to avoid developing something new.

Despite these challenges, there are several biosimilars on the market today. Unfortunately, biosimilars face challenges even once approved. Providers and patients may not quickly accept the new drug, and biosimilars cannot be readily substituted by the pharmacist as a generic. Unlike the price cut of 80% for generic drugs, biosimilars are only 15-20% cheaper than the original. There are currently more than 20 biosimilar clinical trials underway in the U.S., with hopes that more biosimilars will be available soon, but the “when” is unpredictable.

Pharmacy Management – More Important Than Ever

OptumRx Programs to Manage Pharmacy Trend

  • Select and Premium Formulary options
  • Tiers, exclusions, utilization management edits (see below)
  • Guided by expert clinicians from OptumRx Pharmacy & Therapeutics (P&T) Committee 
  • Prior authorization ensures safe and clinically appropriate medication use
  • Step therapy programs promote trial of lower-cost, conventional therapy prior to approval of higher-cost medications
  • Quantity limits ensure adherence to FDA-approved dosing guidelines 
  • Utilization management edits
  • 24/7 availability of BriovaRx staff provides individualized support and promotes adherence, safety and efficacy of high-cost drugs 
  • Exclude or Prior Authorization for new-to-market drugs allows time (typically 3-6 months) for OptumRx P&T Committee’s review and clinical decision on formulary status and/or coverage requirements 
If you have questions about managing pharmacy costs, please contact your MedCost Benefit Services Account Manager for more information.
Zafeira Sarrimanolis, PharmD is the Pharmacist for MedCost. She assists with pharmacy benefit planning and development and offers proactive analysis and clinical recommendations to help manage pharmacy trend.