Managed Care

Retail pharmacies miss out on specialty drugs

Retail pharmacies are less likely to dispense specialty drugs than in the past, according to the Pharmacy Benefit Management Institute’s 2009–2010 Prescription Drug Benefit Cost and Plan Design Report. In 2007, nearly 37 percent of employers surveyed said their plan benefit design allowed retail pharmacy to dispense specialty drugs, but that dropped to 28 percent in 2009. The report points out that not all retail pharmacies are equipped to handle refrigeration, compounding, and patient counseling that often go with specialty products. Depending on how the benefit design is structured, the pharmacy benefit can be delivered as part of the medical benefit (carved in) or it can be designed and managed separately from the medical benefit (carved out). The report says that 70.9 percent of carve-out employers offer a specialty pharmacy benefit, compared to only 41.6 percent of carve-in employers. Carve-out employers, which usually have 1,000 or more employees, are more likely to use their PBM as an exclusive supplier of specialty drugs. These employers are more likely to use pharmacy benefit managers and specialty pharmacies to manage the cost and utilization of specialty drugs. The 2009 survey was completed by 417 U.S. employers representing more than 7 million members.

  • My PBM is the exclusive supplier of specialty drugs
  • Our plan has established quantity limits for specialty drugs
  • Our plan requires all specialty drugs filed through our PBM contract to be dispensed from the PBM’s designated specialty pharmacy
  • We have restricted coverage in our medical plan to channel specialty drugs to PBM
  • Our plan permits dispensing of specialty drugs at retail pharmacies

*Respondents in 2008 were made up of slightly larger employer groups, compared to respondents in 2007 and 2009.

Source: Pharmacy Benefit Management Institute. 2009–2010 Prescription Drug Benefit Cost and Plan Design Report

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