While U.S. healthcare spending grows 4% a year, prescription drugs are on an even steeper climb, rising 8% in 2022.1 To rein in costs, employers are paying close attention to the main driver of prescription drug spending: specialty pharmacy.
Medical specialty drugs are prescribed for chronic and complex conditions such as Crohn’s disease, rheumatoid arthritis, multiple sclerosis and cancer, and are delivered by injection or infusion under the care of a healthcare professional. Single treatments can cost $5,000 or more, with the annual cost for one specialty medication used on a chronic basis reaching $84,442.2 Specialty drugs now account for 51% of total prescription drug spending.3
And costs keep rising: In 2015, specialty drug spending totaled $162 billion. By 2025, it is estimated to reach $375 billion.4 Because many people living with complex diseases are still working, healthcare costs are significantly increasing for employers. In fact, just 2% of employees account for 50% of all drug spending.5
Blue Cross offers a member-centered and provider-friendly alternative
The common approach to control specialty drug costs is prior authorization, used by 97% of employers.6 Due to misaligned incentives between payers and providers, prior authorization can cause strained relationships when provider prescription requests are questioned or denied.
Through Prime Therapeutics LLC (Prime), its pharmacy benefits administrator, Blue Cross and Blue Shield of Minnesota equips self-insured and fully insured employers to control specialty pharmacy costs while maintaining high provider and member satisfaction. Prime recently acquired Magellan Rx, an industry-leading specialty pharmacy benefits manager with 20 years of experience. As of August 1, 2024, through Prime, Blue Cross offers employers a comprehensive utilization management and prior authorization strategy, based on industry best practices and evidence-based clinical research.
Thanks to a proprietary web-based application and automated review process, 60% of prior authorizations are approved in six minutes or less, improving practice efficiency. Prime reports the fast approval process, with fewer appeals and grievances, results in a 98% provider satisfaction rating.7
Reviews are supported by dedicated clinicians, pharmacists, oncologists and specialists — including key opinion leaders from the Prime expert clinical network. Decisions are made on evidence-based criteria for dose and indication. Clinical sources include guidelines from the National Comprehensive Cancer Network and American Society of Clinical Oncology, Food and Drug Administration labeling, Centers for Medicare & Medicaid Services and peer-reviewed literature.
When consultation is part of the process, providers are contacted by a peer physician, matched by specialty. This enables the provider to discuss the specifics of each case so determinations can be made in a transparent, collaborative manner. When clinically appropriate, less costly drugs are suggested, such as generics or biosimilars. The focus on provider consultation results in fewer denials and delays — a low 6% denial rate7 and reduced provider administrative burden — so members get timely access to the drugs and therapies they need.
Claim audits reduce waste
Post-service claim audits ensure medical benefit drugs are paid correctly through dose and frequency-specific claim-to-authorization matching. By identifying inappropriate prescribing and waste, Prime and Blue Cross can pass the savings to employer health plans.
Blue Cross is committed to managing specialty drug costs to maintain affordability of healthcare benefits and enable members to access the drugs and therapies they need. Our relationship with Prime extends the high quality of our clinical programs and operational excellence in prior authorization. Through focused attention on expensive specialty drugs and complex medical conditions, Blue Cross protects your healthcare investment to earn your trust as Minnesota’s #1 ranked health plan.8
To learn about Prime, specialty pharmacy management, high-cost disease states and more, contact your Blue Cross account representative.