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Market Research Report
Specialty Pharmaceuticals in the United States: Changing Patterns of Distribution and Reimbursement
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This publication has been discontinued on December 21, 2011.
Abstract
Introduction
Specialty pharmaceuticals are among the most expensive products in health
plans’ pharmacy budgets. Thus, the provision and use of these drugs in
both the commercial insurance and Medicare arenas is of great interest to
several key stakeholders: specialty pharmacy vendors, payers, physicians,
patients, and drug manufacturers. These players will benefit from a buoyant
U.S. market for specialty drugs, which is set to grow vigorously for decades
to come.
Get the Answers Needed to Shape Your Strategy
Payers want their specialty pharmacy vendors to provide therapy or disease
management services. Will PBMs, wholesalers, and MCOs continue to make
acquisitions to establish a presence in this market? Can smaller companies
continue to thrive by carving out a niche for themselves in areas such as
specialized disease management?
Health plans are increasingly moving physician-administered specialty drugs
from the medical benefit to the pharmacy benefit. How will this move
improve health plans’ ability to implement cost-containment strategies?
How will it affect physicians’ prescribing powers?
The pharmaceutical and biotechnology companies that are developing
specialty drugs will need to adapt to a rapidly changing environment. How
can these companies shift their sales focus to address these changes? How can
they secure good formulary placement for their products?
The launch of new specialty treatments will likely increase payers’
bargaining powers; specialty drug classes that currently have little
competition could become more crowded. How will this competition affect
pricing of drugs? How will it affect manufacturers’ negotiations with
health plans (or their PBMs) on discounts or rebates?
Scope
- Evolution of specialty pharmacy: changes in the specialty pharmacy
market since its inception in the late 1970s; mergers and acquisitions in the
specialty pharmacy market.
- Services offered: a variety of services from specialty pharmacy
vendors.
- Commercial insurance: health plan coverage of specialty
pharmaceuticals as a medical benefit and a pharmacy benefit.
- Medicare: Medicare coverage of specialty pharmaceuticals under Part
B and Part D.
- Outlook and implications for stakeholders: outlook for specialty
pharmacy vendors, payers, physicians, patients, and drug manufacturers.
Mentioned in This Spectrum Report:
Companies
- Accredo Health
- AdvancePCS
- Aetna
- Aetna Specialty Pharmacy
- AmeriSource Bergen
- Aon Consulting
- Axium Healthcare Pharmacy
- BioScrip
- Caremark Rx
- Centocor
- Cigna
- CuraScript Pharmacy
- Curative Health Services
- CVS
- Dyckman & Associates
- Eckerds Specialty Pharmacy
- Express Scripts
- Genzyme
- Gilead
- Health Strategies Group
- Highmark
- IMS Health
- Kaiser Permanente
- McKesson
- McKesson Specialty
- Pharmacy
- Medco Health Solutions
- Medco Specialty Rx
- Medmark
- Novartis
- Option Care
- Pharmacare Specialty
- Pharmacy
- PrecisionRx
- Priority Healthcare
- Specialty Disease
- Management Services (SDM)
- Stadtlanders
- Tel-Drug
- UnitedHealth Group
- UnitedHealth Pharmaceutical
- Solutions
- United Therapeutics
- US Bioservices
- Walgreens
- Walgreens Specialty Services
- WellPoint/WellChoice
- Zitter Group
Organizations
- American Medical Directors
- Association
- American Society of
- Consultant Pharmacists
- Centers for Medicare and
- Medicaid Services (CMS)
- Health Research Educational
- Trust (HRET)
- Kaiser Family Foundation
- (KFF)
- Medicare Payment Advisory
- Commission (MedPAC)
- Pharmacy Care Management
- Association (PCMA)
Table of Contents
- Executive Summary
- Strategic Considerations
- Stakeholder Implications
- Introduction
- Specialty Pharmacy
- Evolution of Specialty Pharmacy
- Services Offered
- Coverage of Specialty Pharmaceuticals
- Commercial Insurance
- Medical Benefit
- Pharmacy Benefit
- Medicare
- The Medicare Competitive Acquisition Program
- Outlook and Implications for Stakeholders
Tables
- 1. Ownership of Leading Specialty Pharmacy Companies
- 2. Express Scripts’ Coverage of Specialty Drugs
Figures
- 1. Private Health Plans’ Average Reimbursement Rates for Specialty
Drugs, Fall 2004 and 2005
- 2. Percentage of Covered Workers in Formularies of Various Structures,
2000-2006
- 3. Percentage of Covered Workers Required to Pay Copayments and/or
Coinsurance by Formulary Tier, 2006
- 4. Evolution of Mean Patient Coinsurance Rates for Generics, Preferred
Branded Medicines, Nonpreferred Branded Medicines, and Fourth-Tier Drugs,
2000-2006
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