Prime Therapeutics sets the parameters of specialty-drug purchasing discussions

Pharmaceutical CommercePharmaceutical Commerce - November/December 2013

Blue Cross/Blue Shield PBM says seven steps help manage costs

As the value of specialty products—injectables and other complex therapies not generally available as pill bottles at the local pharmacy—eat up more of the pharmacy-benefit budget, pharmacy benefit managers (PBMs) and others are focusing more of their efforts on controlling their costs. The issue is of critical concern: Prime says that while specialty drugs are consumed by 1% of current commercial health plan members, they represent 30% of total drug spend. Projections are that they will represent 50% of drug spend by 2018.

Prime Therapeutics, the PBM run by 13 regional Blue Cross/Blue Shield health plans, has issued a report outlining what these controls could be. In effect, the Prime Therapeutics report is the user’s manual for health plans and sponsors to manage their specialty spend better. But some of it can also be read as the negotiating stance of Prime and other PBMs in confronting escalating drug costs.

The seven steps are:

  • Bridge the benefit divide: use combined pharmacy and medical benefit data to see the full scope of specialty spending and seek solutions.
  • Focus on the biggest issues: use combined data to target the most urgent issues and focus on the areas that can provide the greatest return on investment.
  • Narrow the specialty network: use cost-effective distribution channels and limit the number of distributors to secure lower prices.
  • Embrace a management mindset: make sure the right specialty drugs are used properly by those who will benefit the most.
  • Promote preferred drug use: build plans that encourage desired behaviors.
  • Protect members from high costs: limit members’ out-of-pocket costs and use available tools to reduce the burden on highly vulnerable members.
  • Pick the right partner: select a trusted advisor with comprehensive capabilities and deep connections to help anticipate and address specialty drug challenges.

Some of these steps imply keeping a tight rein on which health-plan members get the specialty products (no surprise there). Step 7, “picking the right partner,” is a message to employers and health plans that Prime Therapeutics is on top of the situation.

But of note to manufacturers should be Step 3, “narrow the specialty network.” In this practice, PBMs will seek to deal with only a few distributors—or one only—or, perhaps, the PBM’s own channel—to get a preferred price. There has been a distinct trend for specialty pharma companies to explore “limited distribution networks” as a way to control the quality of service accompanying their drugs.

“Shifting from large, open networks to a more narrow network increases leverage, resulting in better pricing,” says Prime, which operates its own specialty pharmacy, and can provide “white bagging” services—sending a drug it has purchased directly to a physician’s office for administration to the patient. The Prime report also mentions coupon use: “If used appropriately, coupons can support adherence.” The key, according to Prime, is to limit coupons and other patient assistance to those who must take certain medications.

The Prime Therapeutics report is available online at:

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