Specialty Drug Reimbursement by Pharmacy Type

IndustryManaged Care/ PBM
ProblemPHSI was asked to investigate specialty drug reimbursement by pharmacy type for a health plan. The client was focused on comparing their specialty pharmacy to the PBM’s specialty pharmacy and all other retail pharmacies. The client was beginning the RFP process for PBM services and wanted to examine the margins its PBM was making on their specialty prescriptions.
PHSI SolutionPHSI utilized the health plan’s specialty drug claims data to generate several data views by pharmacy type, single source drug, multi-source drug , drug specific examples and segmented outliers. PHSI provided profit estimates for the PBM specialty pharmacy.
ResultsThere was no single pharmacy type that consistently offered the lowest costs for specialty drugs. The lowest cost option was drug dependent. However, there were many drugs where the differences were negligible, and there were no clear winners. PHSI was able to demonstrate the client’s PBM was making a healthy margin on specialty prescriptions. With this information the client was in a better position for the upcoming RFP and negotiation process.