The topic of specialty drugs is of great interest to benefit plan providers, and it’s no wonder. At CarelonRx alone, 3.2% of members are on a specialty medication, and 60.2% of total drug spend is for specialty medication (medical + pharmacy).*

But we can’t take for granted that specialty drugs are well-understood by all involved. So, here’s a quick primer.

While there is no standard definition of a specialty drug, most definitions share these attributes:

  • High cost
  • Used to treat complex disease states, although we are seeing specialty drugs be used to treat more common conditions
  • Frequent dosing adjustments and intensive clinical monitoring to decrease the potential for drug toxicity and increase the probability for beneficial treatment outcomes
  • Varied dosage forms including oral, self-injectable or infused medications
  • Limited or exclusive product availability and distribution
  • Administered at varying sites of care, including home infusion, doctors’ offices and infusion centers

Additionally, many specialty drugs are used by a small subset of patients with complex, 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 high costs associated with specialty drugs.

Examples of conditions treated with specialty drugs
Crohn’s disease
Multiple sclerosis
Cystic fibrosis
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Ulcerative colitis
Hereditary angioedema

Cost aside, you may be asking yourself if, given the complexity of these drugs, the patients who use them can be served by traditional retail pharmacies.

The answer is typically “no.” Traditional retail pharmacies do amazing work supporting the needs of the millions of Americans who rely on them for medications to treat both acute and chronic conditions. But traditional retail pharmacies can’t be all things to all people. That’s where specialty pharmacies come in.

The role of specialty pharmacies

Specialty pharmacies are designed to serve as a single source for pharmacy, clinical, and patient care for those whose conditions are treated with specialty drugs. As such, the clinical staff at specialty pharmacies have extensive expertise in chronic and complex diseases and treatments, offering a more in-depth level of care for plan members.

Further, specialty pharmacies typically have care teams, including nurses and pharmacists, who serve as experts about various drugs and disease states, enabling them to support patients’ holistic needs — whether clinical, educational, or financial.

Given the complexity of specialty drugs and the critical role they play in your pharmacy benefit offering, it’s important that you understand them and 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.

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, 2023

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