Medical Benefits (uncontrolled – lacks pharmacy oversight) vs. Pharmacy Benefits (controlled)

The big issue: Nearly half of all specialty medications are currently billed through the medical benefit, which lacks the aggressive cost-control strategies and oversight of the pharmacy benefit: 1 in 5 prior-authorization requests is medically unnecessary and 15% of medical drug claims are paid inaccurately. This has resulted in $9 billion of wasted specialty costs.¹ Within the specialty pipeline like oncology, up to 70% of total payer oncology and supportive drug spend, are covered under the medical benefit. Oncology drug trend is expected to rise 15% annually through 2020.

Specialty drugs now account for 40% of the $450 billion annual pharmaceutical market and that number is expected to continue to increase with no clear end in sight. It is estimated by 2020 over 50% of outpatient drug spend will be in specialty medicine.²

It’s important for payers to understand the complexity of specialty medications, especially those managed under the medical benefit, and create a strategy to manage these costly therapies.

ARC’s Medical Management Solutions have sustained drug savings of 15%

1.The Lab-Express Scripts: Medical Benefit for Specialty Rx. 2015 Express Scripts infographics
2.Drug Topics. Published on April, 2019