We recently caught up with Mark Campbell, vice president at RxBenefits, to discuss the current state of specialty medications, key strategies for benefits advisors and employers, and what to expect in the second half of 2023 and beyond. 

Can you explain what a specialty medication is, and how it can impact overall drug spend?  

Unfortunately, there is not an industry-wide definition for "specialty" medications.  Specialty status is determined by each PBM. Historically, the specialty designation was applied to medications that were classified as biologics or medications that required special storage and handling. Today, specialty designation can include high-cost oral therapies and medications that have limited distribution.

How can benefits brokers/advisors and employers ensure their members are taking the appropriate and necessary specialty medications?

Specialty medications account for 50% to 55% of the overall program cost for most employers. Cost for specialty medications can range from <$1,000 to more than $50,000 per month. The average specialty medication cost is approximately $7,200 (pre-rebate). Because the vast majority of specialty medications are considered maintenance therapy, it is essential to have a review process in place to validate that the requested medication is appropriate clinically first and foremost. Because multiple therapeutic options are available for most conditions, it is also necessary to ensure that product choice is based on all available options and takes into consideration the relative cost of therapy. For example, there are multiple choices for atopic dermatology; while all may have strong clinical data to support their use, the net cost to an employer can often vary by $20,000/year or more.