Specialty Drugs

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Specialty Drugs

What are specialty drugs?

Although there is no standard definition for what qualifies a drug as a specialty drug, specialty drugs typically require special handling, administration, or monitoring and are difficult to manufacture. specialty drugs are also generally expensive and are used to treat chronic and/or complex conditions such as multiple sclerosis, cancer, chronic kidney failure, cystic fibrosis, HIV/AIDS, Crohn’s disease, and rheumatoid arthritis.

Despite comprising less than 1% of all prescribed medications in the U.S., in 2013 specialty drugs costs accounted for 27.7% of total prescription drug spending. Spending on specialty drugs is expected to increase 63% between 2014 and 2016, driven primarily by a huge increase in spending on a new medication which treats Hepatitis C. Furthermore, from 2011 to 2013 the majority of all FDA drug approvals were for specialty drugs.

Filling specialty drug prescriptions

Prescriptions for specialty drugs can be filled at retail pharmacies but keep in mind that not all pharmacies dispense specialty drugs. Specialty drugs can also be obtained through certain mail order pharmacies such as Walgreens Specialty Pharmacy or Accredo - Express Scripts’ specialty pharmacy. Keep in mind that you may not be able to obtain a 90-day supply of specialty drugs and some insurers such as BCBS may impose a 15-day limit to save beneficiaries on copay costs and reduce drug waste.

Sometimes a manufacturer will limit the distribution of specialty drugs and you may not be able to fill your prescription through your local retail pharmacy. Limited distribution specialty drugs are noted with an “LD” following the name of the specialty drug on the prescription. Furthermore, if the prescribed specialty drug’s name is followed by a “PA” (prior authorization), your insurer must review why the specialty medication was prescribed before they agree to pay. Without prior authorization from the insurer you may have to pay more out-of-pocket costs for the specialty drug or you may have to cover the entire cost of the drug yourself.

Specialty Drug Costs

In February 2014 HealthPocket performed a study on the impact of the Affordable Care Act on drug costs for consumers. We found that on average specialty drug coinsurance fees decreased across all metal tiers while copays increased substantially across all metal tiers:

 2013 Pre-ACA Plans2014 Bronze Plan2014 Silver Plan2014 Gold Plan2014 Platinum Plan
Average Specialty Drug Copay$58.46$190.65 (225% Increase)$166.41 (185% Increase)$157.55 (170% Increase)$126.50
(116% Increase)
Average Specialty Drug Co-Insurance35% of drug cost paid out-of-pocket34% (3% Decrease)31% (11% Decrease)28% (20% Decrease)30% (14% Decrease)

HealthPocket recently conducted a study examining which 2015 Obamacare metal plan would be the best choice for consumers taking specialty drugs. We looked at average annual out-of-pocket costs for five specialty drugs used to treat inflammation, multiple sclerosis, cancer, HIV, and growth deficiency. Results of our analysis found that out-of-pocket specialty drug costs for platinum plans were 78% lower than bronze plans, 74% lower than silver plans, and 64% lower than gold plans. The following table displays the average total annual 2015 costs (including premiums and out-of-pocket costs) for enrollees aged 30, 40, and 50 that take specialty drugs listed in a plan’s formulary (the list of covered drugs).

AgeBronzeSilverGoldPlatinum
30$9,568.78$9,353.86$8,326.36$6,670.70
40$9,970.26$9,843.64$8,885.99$7,332.90
50$11,396.44$11,583.55$10,874.03$9,685.48

Individuals taking specialty drugs should not simply choose a plan based on low premiums or metal level. To mitigate high out-of-pocket costs it is important to consider out-of-pocket maximums and make sure that the specialty drugs you take are included in your plan’s formulary. Other things to consider include drug restrictions such as prior authorization, supply limitations, or step therapy, and whether the plan includes a separate drug deductible (if yes, how much is it?).

Top Specialty Conditions and Specialty Drugs

Express Scripts, the largest pharmacy benefit management company in the United States, ranked the top therapy classes for specialty drugs with respect to 2013 per-member-per-year spending. In addition, they determined the top drugs by market share in each of those therapy classes. Express Scripts’ top eight specialty therapy classes and the top specialty drugs for each therapy class are listed below,1 as well as the cost of a typical prescription for each drug.2

1. Inflammatory Conditions

Top Specialty Drugs by Market Share:

Humira:
$2,942.35 (2 pens of Humira 40mg/0.8ml)
Enbrel:
$2,942.87 (4 sureclicks of Enbrel 50mg)
Stelara:
$8,024.53 (1 syringe (0.5ml) of Stelara 45mg/0.5ml)
Cimzia:
$3,017.20 (1 kit of Cimzia 200mg/ml)
Simponi:
$3,245.31 (1 syringe (0.5ml) of Simponi 50mg/0.5ml)

2. Multiple Sclerosis

Top Specialty Drugs by Market Share:

Copaxone:
$6,052.25 (30 syringes of Copaxone 20mg/ml)
Avonex:
$4,948.44 (4 syringes of Avonex 30mcg/0.5ml)
Rebif:
$5,265.34 (12 syringes of Rebif 44mcg)
Gilenya:
$5,298.56 (28 capsules of Gilenya 0.5mg)
Tecfidera:
$5,364.95 (60 capsules of Tecfidera 240mg)

3. Cancer

Top Specialty Drugs by Market Share:

Gleevec:
$9,119.95 (30 tablets of Gleevec 400mg)
Xeloda:
$1,124.73 (84 tablets of capecitabine 500mg)
Revlimid:
$14,238.70 (30 capsules of Revlimid 10mg)
Lupron Depot:
$937.80 (1 kit of Lupron Depot 3.75mg)

4. HIV

Top Specialty Drugs by Market Share:

Atripla:
$2,186.49 (30 tablets of Atripla 600mg/200mg/300mg)
Truvada:
$1,369.70 (30 tablets of Truvada 200mg/300mg)

5. Growth Deficiency

Top Specialty Drugs by Market Share:

Norditropin:
$5,096.07 (5 cartridges (1.5ml) of Norditropin 15mg/1.5ml)
Genotropin:
$1,174.68 (4 kits of Genotropin 0.4mg)
Humatrope:
$586.15 (1 kit of Humatrope 6mg)
Nutropin AQ:
$894.46 (1 vial (2ml) of Nutropin AQ 10mg)
Omnitrope:
$892.24 (1 cartridge (1.5ml) of Omnitrope 10mg/1.5ml)

6. CNS Disorders

Top Specialty Drugs by Market Share:

Xyrem:
$3,429.30 (1 bottle (180ml) 500mg/ml of Xyrem oral solution)
Vivitrol:
$1,261.81 (1 kit of Vivitrol 380mg)
Xenazine:
$5,501.65 (90 tablets of Xenazine 12.5mg)
Sabril:
$9,199.65 (120 tablets of Sabril 500mg)
H.P. Acthar:
$31,561.60 (1 vial (5ml) of H.P. Acthar 80 units/ml)

7. Respiratory Conditions

Top Specialty Drugs by Market Share:

Xolair:
$884.55 (1 vial of Xolair 150mg)
Pulmozyme:
$2,814.53 (1 carton (30 ampules) of Pulmozyme 1mg/ml)
TOBI:
$7,985.62 (1 carton (56 ampules) of Tobi 300mg/5ml)
Cayston:
$6,607.72 (1 kit (28 days) of Cayston 75mg)

8. Anticoagulants

Top Specialty Drugs by Market Share:

Fragmin:
$969.58 (1 carton (10 syringes) of Fragmin 12500iu/0.5ml)
Lovenox:
$173.99 (10 syringes 40mg/0.4ml of enoxaparin)
Arixtra:
$4,380.24 (10 cartons (10 syringes) of fondaparinux 7.5mg/0.6ml)

Sources:

Prices Soaring for Specialty Drugs, Researchers Find. New York Times. April 15, 2014.
Specialty Drug Spending at Lowest Rate Since 2007. Express Scripts. April 8, 2014.
Specialty Drug Approvals in 2013. Express Scripts. March 26, 2014.
1The top eight specialty therapy classes and the top drugs by market share for each therapy class can be found via links from this page
2Specialty drug cost estimates from goodrx.com used the CVS Pharmacy coupon price in zip code 10001.


 

 

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