Employer Clinic, Employer Health Benefits

RxStewardship: S is for Specialty

Week 10 – R X S T E W A R D S H I P


Charles Duell, who served as the Commissioner of the US Patent Office from 1898 to 1901, is often mistakenly attributed as saying something along the lines of “Everything that can be invented has been invented.” Over time, this has been proven to be an ‘urban legend’; however, later in life, he did remark:

 In my opinion, all previous advances in the various lines of invention will appear totally insignificant when compared with those which the present century will witness. I almost wish that I might live my life over again to see the wonders which are at the threshold.

Although Duell made this statement in 1902, it rings true even 119 years later. Perhaps nowhere is his comment more relevant than in the pharmaceutical industry – especially in the area of specialty medications. Developments in technology and an understanding of the human body at unprecedented levels of detail have led to amazing advances in medication therapy. Newer treatment options for diabetes, cancer, cardiovascular conditions and autoimmune diseases abound. Additional treatments for cancer, diabetes and Alzheimer’s disease are on the horizon as are truly novel treatments using gene therapy. Those who have previously struggled with a lifelong condition, those whose disease has progressed beyond traditional medications and those who have faced an ‘incurable’ malady have been given newfound hope for relief.

Unfortunately, the financial implications of these advances are both substantial and well documented. While this issue is not new for employers, the future size and scope of these challenges continues to be realized.  


Although specialty medications typically account for less than two percent of all prescriptions, it is not unusual for them to account for 45% – 55% of an employer’s entire pharmacy benefit spend. It is anticipated that specialty pharmacy spend will exceed $360 billion in 2021, with 9 of the top 10 best-selling medications (by revenue) being classified as specialty drugs. This compares to 7 of the top 10 in 2014 and 3 in 2010.  In 2020, 83% of medication approvals were for specialty pharmaceuticals, an increase from 66% in 2019. Specialty pharmacy prices are likely to increase by 11.5% in 2021 as compared to a 2.8% price increase for non-specialty pharmaceuticals.  Furthermore, prescription volume for specialty medications increased 6% in 2020 as compared to flat utilization for non-specialty medications.

In their 2021 Drugs to Watch report, Clarivate™ identified four medications which they believe will produce more than $1 billion each in annual sales within five years. While less than half-dozen gene therapies are currently FDA-approved (at an average cost exceeding $1 million each), over 900 clinical trials are currently in progress to evaluate future gene therapies.


These trends point to employers facing further specialty medication-related cost pressure. The most common cost containment approaches implemented to date have involved increasing copayments and deductibles, instituting prior authorization and step therapy programs, narrowing the specialty medication formulary list and using patient assistance programs. Some employers have chosen to simply exclude specialty medications altogether. It is certainly understandable that employers will need to take the steps necessary to protect the viability of their benefit plan and the company at large and Northwind can help provide options and solutions; however, one wonders if there are steps that can be taken to attenuate costs while maintaining plan access to specialty medications for employees.

  • Ensure the patient is taking the medication properly. Having a pharmacy team available to provide customized 1:1 education and to answer questions that come up over time is a key component for long-term patient success. Many specialty medications require more diligence than simply taking a tablet or capsule. Regimens can be complicated. They can be time sensitive. They can have specific storage requirements. Proper use often requires a guiding hand and consistent support.
  • Ensure medication adherence. The most expensive medication is the one that isn’t taken. Employers need programs in place to ensure patient adherence with their medication regimen. Patients who need specialty medications often have complex diseases, cognitive challenges or extensive medications lists. Over a period of time, it is easier to lose track of whether a medication was taken than one would think.
  • Have a plan to measure overall outcomes. It is easy to focus solely on the cost of the medication, but it is important for employers to take a broader view. Metrics such as overall benefit costs (medical and pharmacy), absenteeism and productivity trends can all be important components of measuring the overall investment that has been made in specialty medications.
  • And last, but certainly not least – focus on prevention. This post started with a quote from Charles Duell and will end with one from Benjamin Franklin – “An ounce of prevention is worth a pound of cure.” Any effort employers can make to help prevent or control disease will pay dividends. Regular health education, benefit plan design that emphasizes preventive measures and employer-sponsored biometric checks and health screenings can be of tremendous value. Clinical programs that help employees with tobacco cessation, weight management, pulmonary disease, cardiac disease, diabetes etc. can not only provide short-term savings, but can prevent disease progression leading to a need for certain specialty medications.

The financial implications of specialty medication use is understandably a cause for concern but if you would like to explore ways to continue to provide a robust, meaningful benefit plan for your employees while protecting your organization, please reach out. Let’s have a conversation!

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