With a proliferation of complex chronic conditions and a growing drug pipeline, many of which are costly specialty medications, it’s imperative to select a pharmacy benefit manager (PBM) that understands the unique requirements of managing specialty patients, their conditions and the available medications. In fact, in 2020, nine of the 10 best-selling drugs by revenue will be specialty drugs. Compare this to just three of the top 10 being specialty drugs in 2010 and seven of the top 10 in 2014. The growth of drugs treating complex specialty conditions is clear and doesn’t appear to be slowing.
PBMs must take a common sense approach to specialty care. This requires a balanced strategy that prioritizes value over volume—applying appropriate clinical guidelines, knowing each unique case and providing individualized care. Are your clinical controls too low, too high or just right?
EnvisionRx’s SpecialtyCare model provides a thoughtful approach, unique to each specialty condition, which carefully considers clinical effectiveness, patient experience and economic impact. The SpecialtyCare model is founded on four strategies with the ultimate goal to consistently achieve optimal outcomes—for each patient and each plan sponsor, each and every time.
- Condition-focused clinical controls consider the specific disease state, target populations and the efficacy of drug options available. Complex conditions cannot be effectively treated with a one-size-fits-all approach. Balanced clinical controls are a necessity. Without this balance, the result will be a high number of formulary exclusions on drugs with real clinical value and the inclusion of some drugs due to their high rebates. Envision’s condition-focused clinical controls produce lower member disruption and better health outcomes.
- Individualized care requires applying appropriate clinical guidelines and understanding each patient and their prescription therapies. A PBM partner with proven patient experience helps patients better understand their condition and have confidence in their treatment options for better health outcomes. EnvisionRx spends the necessary time per patient assessing the gaps in care, which include medication adherence, co-morbidities within conditions, risks and readiness for therapy, as well as medical benefit.
- True integration provides our care management teams at both EnvisionRx and our specialty pharmacy, EnvisionSpecialty, with the entire prescription claims utilization history through direct access to the same technology platform. This gives us the ability to efficiently and quickly identify care gaps, duplications of therapy, contraindications and actionable clinical information. Integration is more than just ownership or partnership, true integration means real-time data access and the sharing of specialty patient clinical insights and doesn’t add another layer of administration and performance management.
- Meaningful data is derived from our patient engagement and disease activity tracking tools. This robust data allows us to provide our clients with real insights on plan performance and recommendations on improvement opportunities. Trends in the data around costs and utilization show us actions we can take to reduce drug spend and close care gaps, like abandonment, disease progression, duplication of therapy and incorrect dosages.
EnvisionRx’s common sense approach and dedication to the patient is the difference between merely processing claims and positively impacting the quality of a patient’s life. Our thoughtful care management includes clinical controls tailored to the medical condition and the drugs available for them. This, paired with our proven patient experience, delivers coordinated care that improves patient health outcomes and ensures use of the most cost effective drug therapies for better plan outcomes.
 Pharmaceutical Care Management Association (PCMA). Specialty Drug Trends. Retrieved from https://www.pcmanet.org/pcma-cardstack/specialty-drug-trends/ on 9/19/19.