Increased availability of high priced specialty drugs is increasing payer costs at an unsustainable rate. Employers and plan sponsors are challenged to maintain affordable programs while covering the cost of these expensive prescriptions. Utilization management is a foundational cost management strategy.

Specialty drugs are typically newly available to treat less common or very complex diseases. As a result, many physicians are not up to speed on appropriate effective usage. It has been reported that it’s not uncommon in cancer treatment, for example, for a third of oncology drug regimens to be at variance to evolving guidelines.

Closely monitoring the appropriate use – medical necessity and effectiveness – is key. Here are 4 steps to help ensure effective specialty drug utilization:

  1. Prior Authorization – Requiring prior authorization for specialty drug prescriptions can be a very effective tool to support medically appropriate usage.
  2. Step Therapy – Step therapy means trying less expensive drugs first – and it ensures that if some less expensive solution can work, it is given a chance to do so.
  3. Dosage Management – When using dosage management, the number of doses is limited until it is determined whether the patient is responsive to the therapy. Paid-for but ineffective drugs are extremely wasteful at these prices and potentially dangerous.
  4. Care Coordination – This is a key utilization management best practice, particularly for patients with chronic illnesses. Managing the integration of benefits and clinical care, including appropriate coordination of prescription drugs as part of overall treatment, can maximize patient compliance and reduce costs.

Utilization management is just one cost management strategy employers and payers are leveraging to combat specialty drug cost trends. Download the free ebook below to learn more.

Payer Strategies for Specialty Drug Management free eBook

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