The Value of High-Touch Specialty Pharmacy Medical Benefit (J-code) and PBM Carve Out – The Evolution of the TPA-Employer SpecialtyRx
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Tuesday, May 9, 2023
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9:15 am – 10:15 am
As we are grasping the fact that specialty drug cost continues to rise, the need to have key accountability measures in place to maximize cost-savings and plan efficiency is essential for employers to control their healthcare cost. There are key value-levers on both medical and pharmacy benefits to manage for optimal benefit based on clinical and financial factors resulting in improved patient experiences at a lower cost of care. Despite the use of utilizing prior authorization program and a variable copay program, two additional strategies are being increasingly explored in the market: carving-out specialty medications from the PBM and pharmacy benefits. The value of doing this weigh on key important areas to understand, including the difference of these types of specialty medication when excluded from the covered benefit; the key factors to drive when carving-out specialty; the details of current contractual arrangements with your PBM and your plan language and benefit designs; implementing innovative financial solutions and cost saving programs, both financially and clinically; and how to design clinical utilization management programs, manage drug spend through both the pharmacy plan and medical plan, and adopt alternative treatment programs beyond drug therapy. CPE is not available for this session.
Track Session Speakers
- Michael Baldzicki, CRCM
- Chief Brand Officer
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- AscellaHealth
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