Less than half of employers have specialty prior authorization programs under medical benefits, study finds

Walgreens sponsors PBMI survey

PLANO, Texas — Management of specialty drugs under the medical benefit continues to trail management under the pharmacy benefit, according to a new report by the Pharmacy Benefit Management Institute.

The "2013 Specialty Drug Benefit Report," sponsored by Walgreens Specialty Pharmacy, found that 49% of employers had prior authorization programs for specialty drugs under the medical benefit, but 84% had them under the pharmacy benefit, while one-quarter of plans reported having no cost share for specialty medications under the medical benefit, and less than 20% were receiving rebates under medical, compared with 69% under pharmacy.

"At the core of this management gap is employers' lack of visibility into the medical spend," PBMI executive director Brenda Motheral said. "Less than 1-in-4 employers reported being able to track specialty spend under the medical benefit, which is the foundation for active management."

The report was based on a survey of more than 300 employers representing 17.6 million members. It also found that more active management was observed for specialty drugs covered under the pharmacy benefit, including 44% of employers who had separate co-pay tiers for specialty drugs, compared with 36% a year ago. Meanwhile, step therapy adoption under the pharmacy benefit changed from 61% to 58%, and employers that limited specialty quantities to a 30-day supply grew from 58% to 67%. At the same time, knowledge of specialty drug management remained low, with 11% of employers self reporting a low level of understanding, along with 70% reporting a moderate level and 19% reporting a high level. Among small employers, 38% were unsure if they received specialty rebates under pharmacy, and nearly 40% of respondents overall were not sure which site of care had the lowest cost under the medical benefit. Employers also reported the greatest interest in learning more about specialty medical management and specialty co-pay assistance programs.


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