A special case for special medications

A Complex Disease

Jake is an eight year old boy. He plays baseball, loves video games and is trying to master the multiplication tables. Jake also has Fabry disease. It's a rare disorder caused by an enzyme deficiency. Fabry disease is genetic. Jake's mom, Sarah, also has the disease and experiences symptoms similar to her son's.

To treat this disease, both Jake and Sarah need bi-weekly infusions of a specialty medication - a high-cost drug that requires close supervision and monitoring. The drug costs, which are paid by Sarah's employer, are $89,550 every two weeks.

A Simple Solution

A medical expert at CIGNA, Sarah's health services organization, was conducting a review of high-cost medication usage. She saw that Sarah and Jake had just switched their medication infusion site from a children's hospital to a more convenient local facility. This caused the price of their treatments to rise significantly. The medical expert recognized a way to save money without disrupting Sarah and Jake's routines.

The medical director called the family and their doctor to discuss the situation. The medical director then negotiated with the facility to have CIGNA Pharmacy Management provide the specialty medication directly. This significantly reduced the cost from $89,550 every two weeks to $20,499, saving almost $1.8 million per year. Sarah and Jake experienced no disruptions.

More Than Just Cost Savings

Sarah's employer has both medical and pharmacy coverage through one carrier: CIGNA. For Sarah and Jake, that means they benefit from consistent, coordinated clinical programs and patient care. When she has questions, there's just one number to call and one website to visit.

It also means that one organization has a 360-degree view of their health story, and can find unique and productive ways to improve their health and lower costs.

The Truth Behind Carving Out Coverage

Some employers, however, are carving out coverage for specialty medications, moving them from medical to pharmacy benefit plans. They believe this enables them to select "best-in-class" vendors for each product. While that's a perfectly logical approach to buying office equipment, what they don't realize is that medication therapy and overall health are inextricably connected.

Integration Provides Advantages

When it comes to specialty medications, integrated medical and pharmacy coverage can help improve health and lower overall costs:

Coordination of Care

• One carrier helps manage medication costs as well as the involvement of the doctor or nurse, required lab tests and ancillary services.

Cost-Saving Relationships

• Only a medical carrier can take advantage of doctors' special purchasing relationship with drug manufacturers to help lower costs.

Whole Person View    

• One health coach allows for coordination of all resources, specialists and aligned incentives available for the best possible health outcomes.

A Solution for Savings

While diseases like Fabry are rare, the category of specialty medications has a robust pipeline. These medications have the potential to adversely impact total health care costs for all employers. In fact, multiple studies have proven the value of effective medication therapy in lowering medical costs.

A health services organization that understands the entire spectrum of clinical needs - not just the associated medications - can support individuals from all perspectives. Managing a condition that requires a specialty medication can be challenging enough. Partnering with CIGNA for both Medical and Pharmacy coverage can help ease the burden, improve health and lower overall costs.

To learn more, contact:

Claire Marie Burchill, F.S.A.

Vice President, Strategy, Product & Marketing

CIGNA Pharmacy Management

Claire.Burchill2@CIGNA.com

What Are Specialty Medications?

• Made via biotechnology processes to treat the cause of a disease rather than its symptoms
• Target diseases affecting less than 1% of the population, but which are chronic in nature, rarely cured and typically need treatment for long periods of time - maybe for life
• May cost as much per month as other types cost for a full year
• Can limit the progression of a disease and provide improved health outcomes

The Results Are In

A CIGNA study to determined the overall health care cost implications of integrating medical and pharmacy coverage from one carrier versus carving out pharmacy benefits with a third party pharmacy benefits manager. The results are dramatic:

Up to $251 additional medical cost savings per employee per year

These findings confirm the results of a study by HealthPartners, Inc. It found that employers with integrated medical and pharmacy benefits had an average of 3.8 percent lower total cost of care versus similar groups that carve-out pharmacy benefits.

10 Reasons Specialty Pharmacy is So Important

1. Cost - outpaces traditional medications
2. Pipeline - strong, contributing to both cost and use
3. Infusibles - much of specialty development, and are covered under medical, not pharmacy benefits
4. Generics - none, with no regulated pathway
5. Lab tests - increasing to monitor effectiveness and appropriate dosing
6. Legislative activity - mandating patient cost share between medical and pharmacy
7. Other chronic conditions - 60% on specialty medications have at least one other chronic condition - coordination of health coaching is key
8. Risks associated with "carve out" - limits drug access and disrupts patient/physician connection
9. Increased productivity and quality of life - will define value of specialty pharmacy management
10. A total cost of care focus, with holistic patient centered health management and alignment of incentives across all stakeholders - is the best way to drive meaningful results

(legal)

The HealthPartners family of health plans are underwritten and/or administered by HealthPartners, Inc. Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. 

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