The specialty pharmacy landscape continues to evolve as plan sponsors seek advanced solutions to address new treatments for complex conditions, and the needs of plan members who rely on these therapies. Today, specialty drugs account for a significant portion of total pharmacy and medical benefit costs. At CarelonRx, we’re seeing this dynamic play out in real time: while just 4.4% of members use specialty medications, 57.7% of total drug spend is for specialty medication (medical + pharmacy).*
Because these medications are frequently prescribed for serious or chronic conditions, that also means they can be complex to manage. With nearly 67% of specialty drug utilizers having two or more chronic conditions,* effective specialty drug management demands more than traditional pharmacy support.
What defines a specialty medication?
While there’s no universally accepted definition, specialty drugs are typically recognized by the following characteristics:
- High cost.
- Used to treat complex disease states, although they are increasingly used in more common conditions.
- Administered at varying sites of care, including home infusion, doctors’ offices and infusion centers.
- Require regular clinical monitoring and dosing adjustments to manage toxicity and efficacy.
- Varied dosage forms may include oral, self-injectable or infused medications.
- Limited or exclusive product availability and distribution.
Additionally, many specialty drugs are used by a small subset of patients with rare diseases. Because of the small patient populations who will use them, there is less competition to bring these drugs to market — another reason there are higher costs associated with specialty drugs.
Examples of conditions treated with specialty drugs
Crohn’s disease
Multiple sclerosis
Cystic fibrosis
Rheumatoid arthritis
Cancer
Systemic lupus erythematosus (SLE)
Hemophilia
Ulcerative colitis
Hereditary angioedema
The role of specialty pharmacies
Owing to their unique set of characteristics, prescriptions for specialty drugs often require far more support than typical retail pharmacies can provide. High performing specialty pharmacies are structured to offer coordinated, personalized care that spans the pharmacy, clinical, and patient support continuum. This includes:
- Condition-specific clinical expertise.
- Dedicated care teams, including pharmacists and nurses.
- Proactive patient outreach and education.
- Support for medication adherence and side-effect management.
- Assistance navigating benefits and financial resources.
Given the complexity of specialty drugs and the critical role they play in your pharmacy benefit offering, it’s important that you understand the impact they have on the lives of your plan members and their families. While they can be costly, in many cases these drugs offer life-changing benefits to members with rare, complicated diseases.
At CarelonRx, we’ve seen first-hand how integrated specialty care aligns pharmacy and medical benefits to empower patients through personalized support and reduce fragmentation across their healthcare journey.
Never hesitate to reach out to your pharmacy benefit manager (PBM) to have your questions answered. The more you know, the better off your plan members — and your business — will be.
* CarelonRx internal data, 2024.
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