SOURCE: Pharmacy Benefit Management Institute

Pharmacy Benefit Management Institute

February 22, 2012 14:22 ET

Tracking Specialty Drug Spend Covered Under Medical Benefit, Greatest Gap for Plan Sponsors

PBMI Launches First Annual Specialty Drug Benefit Report

PLANO, TX--(Marketwire - Feb 22, 2012) - Less than 20% of plan sponsors can track their specialty drug spend covered under the medical benefit according to a survey conducted by the Pharmacy Benefit Management Institute (PBMI) in the Fall of 2011. The study surveyed 291 employers, health plans and other plan sponsors representing more than 70 million lives. The Specialty Drug Benefit Report, sponsored by Walgreens Specialty Pharmacy (Walgreens), launches today at PBMI's Annual Drug Benefit Conference in Scottsdale, Arizona.

"Our study shows that specialty spend under the medical benefit all too frequently goes unmeasured and unmanaged," says Brenda Motheral, PhD, Executive Director of PBMI. "Given that 50% or more of specialty spend can reside in the medical benefit, closing this gap is a critical priority for plan sponsors."

Specialty drug spend is expected to continue to grow at double-digit rates for the next several years. This survey examines plan sponsors' priorities, concerns, management strategies, outcomes tracking, and educational needs related to specialty drug benefit management. Key findings include:

  • Tracking total healthcare costs for specialty patients is a high priority for plan sponsors although a minority currently has this capability, which shows a definite market need for tools and solutions to close the gap between plan sponsor priorities for outcomes tracking and actual capabilities.
  • The current level of understanding of specialty pharmacy benefit management is low among plan sponsors. Only 19% of employers and 33% of health plans self-report high knowledge of the subject matter.
  • The variability between cost-sharing structures for pharmacy and medical benefit is significant which can disincentivize patients from using the most cost-effective benefit channel. Under the medical benefit, 29% of employers cite "no cost sharing" as the most common specialty cost share design whereas copays are the most common design for employers under the pharmacy benefit.
  • Plan sponsors have an opportunity for more active management of specialty pharmacy utilization under the medical benefit but integration of pharmacy and medical data remains a rate-limiter to more effective management for many plan sponsors.

PBMI gratefully acknowledges the support of Walgreens Specialty Pharmacy (Walgreens) for the sponsorship of this report. Walgreens has no access to the individual responses or raw data gathered, nor do any other third parties. This protects the confidentiality of the survey respondents and ensures the independence and objectivity of this report.

To order the report, visit

Tomorrow, Michael Einodshofer, director of utilization management for Walgreens Specialty Pharmacy, will discuss site-of-care-optimization and present new data that shows cost savings recognizable through alternate treatment sites.

About the Pharmacy Benefit Management Institute

The Pharmacy Benefit Management Institute provides research and continuing education to help health care benefit executives work effectively with pharmacy benefit managers to improve the design and management of drug benefit programs. For PBMI news, visit

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