Abstract
Background: Specialty medicines continue to increase as a percent of spending with biologics representing a large portion of specialty spending. Health plans expect to adjust their formularies to maximize expected savings from biosimilars.
Objectives: Understanding of management of specialty pharmacy (SP), SP products and biosimilars.
Methods: Online survey of health executives: roles + plan information, specialty pharmacies/pharmaceuticals, expected biosimilar coverage/restrictions/copays. Results compared with prior surveys.
Results: The survey was completed by 77 respondents; 57% were MDs, 43% were the senior officer, 19% were payor specific, 9.9% regional, 1.3% therapeutic area specific. 40.5% worked for health plans, 11.4% pharmacy benefit managers (PBMs), 8.9% integrated delivery networks (IDNs), 3.8% preferred provider organizations (PPOs)/ independent physician associations (IPAs), 1.3% Government. Plans were National = 39.2%, regional = 27.5% or local = 33.3%. Plans cover multiple types of members: commercial (68.8% = fee for service [FFS],76.5% = health maintenance organization [HMO]/PPO), Medicaid (Traditional = 36.4%, HMO/PPO = 67.9%), Medicare (71.2%, prescription drug plan [PDP]-only = 50%), Employer/Self-funded = 77.1% and IDN (47.7%,340B Qualified = 43.5%). 48.4% reported the plan’s PBM as their SP provider and providers were restricted by 81% (increased from 51% in 2016) with plans restricting 69% of products/providers to those under contract, 12.1% restricting products available through multiple SPs, 5.2% allowing any SP handling the product and 1.7% carving out their SP agents. Compared with last year, providers shifted ∼6% from independents to internally-provided and currently 46.4% are PBM-owned, 28.6% health plan-owned, 23.2% independent and 16.1% hospital/IDN owned. SP products continue to move from fixed to % copays with more plans determining by group + benefit design. Plans covered clinician-administered products under the medical benefit (44.1%, increased from 15.2%), 1.4% under the pharmacy benefit the remainder used price + plan design. Biosimilar use is expected for all reference product indications 53.1% (decreased from 59.5%), 44.9% will restrict to approved indications (increased from 31%) and 2% indication based. 25% of plans expect the biosimilar to be the only product available, 47.9% expect copays discounted off the innovator, and 27.1% to vary based on approval timing. Biosimilar education will be provided through: different copays = 63.8%, prescriber + patient mailings (72.3% + 59.6%), prescriber + patient calls (40.4% + 23.4%). Expected biosimilars savings: 45.1% <10% in 2018, 47.1% 10–20% by 2020, 58% >20% by 2025.
Conclusions: Costs associated with SPs+SP products have shifted and are expected to grow with some relief coming from biosimilars.
Presenter:
Poster abstracts from the Annual Meeting and Educational Conference for NASP (the National Association of Specialty Pharmacy), September 24–26, 2018, Washington, DC.