Pharmacy

In today's market, the cost of pharmaceutical claims continue to outpace all other healthcare segments. There are over 350 high cost pharmaceuticals in the marketplace with over 1,000 more in the pipeline that are due to enter the market over the next five years.

Of particular note is the rising trend of a subset of medical pharmacy called specialty pharmacy. Each of these specialty medications cost significantly more than traditional drug products taken orally, and currently represent about 5% of overall pharmacy spend. The specialty pharmacy trend rate of 22.5% is nearly double the general pharmacy trend rate of 13.1%.

These specialty pharmaceuticals are billed into the medical benefit (medical pharmacy claims) and although the dollars paid on these claims is significant, have been relatively ignored for overpayment review due to low volume, inadequate claims processing and significant resources necessary to identify and price the product. In sampled data, between 4 % - 13% of all claims are medical pharmacy related.

Guide to Pharmacy Payment Methods

Strategies for Managing High Cost Injectables

Specialty Pharmacy Cost Management Strategies