05/22/2019
Of the drugs approved last year, 31 targeted rare diseases, including 13 cancers, five metabolic diseases, three blood diseases, and three nervous system disorders.1
These approvals bring new and novel therapies — some treating conditions with no other options until now. However due to their unique indications, and in some cases extremely high cost, it’s important to ensure they are being prescribed and used appropriately.
The complex nature of these conditions and their treatments often mean a health care professional must administer the medication. Which means most of the drugs approved today are covered under the medical benefit.
Specialty drugs account for nearly 50 percent of total drug spend.2 This is why it’s important to manage the pipeline of emerging drugs before they come to market.
Pipeline management
Monitoring the pipeline before drugs are approved allows us to have management strategies in place as soon as they are approved and available in the marketplace.
Our process includes identifying the potential number of members that might be impacted by a new drug. We also estimate the cost of select, anticipated high‑cost drugs based on analysis of claims data and existing treatment alternatives. We also review claims for first and second line therapies for each condition to determine the potential impact to our member population.
Pipeline management allows us to evaluate for appropriate benefit coverage and determine if unique administration applies or if prior authorization should be applied before these drugs come to market. It also allows us to implement unique billing strategies and integrate processes across the organization to ensure coverage of these medications when prescribed and used appropriately.
Our pipeline management process enables seamless market entry for our members so we’re ready when that first claim comes in.
We’re committed to continued enhancement of our capabilities for managing medical specialty trend while streamlining consumer experience and improving outcomes.