Specialty Pharmacy

The Solid Benefit Guidance (SBG) Specialty Consulting Solution Provides a Comprehensive A-Z Approach to Secure the Best Cost and Clinical Outcome for Our Clients.

We are highly experienced in leading, designing, implementing and managing integrated specialty pharmacy benefits and utilization management programs across the medical and prescription benefits within health plans and at the plan sponsor level.

While approaches to non-specialty medications are established, new approaches to specialty pharmacy are emerging daily with diversity across all components of the health care industry.

Having the right consultant with you will be critical to your plan’s success.

The rising cost of specialty pharmaceuticals is top-of-mind for every payer. Numerous specialty pharmacy services and management solutions are available in the market place. Utilization of specialty pharmaceuticals, both type and mix of medications utilized, varies across payer groups simply due to variation in niche populations that specialty pharmaceuticals are designed to target.

Now is the time to get your arms around this evolving and critical component of the Prescription and Medical Benefit.

Growth and diversity with specialty medications is a new arena; Specialty drug spend is projected to reach 50% of total Drug Spend by 2017.

There are a number of critical pathways needed to establish a specialty drug strategy and it is important for payers to fully understand their member demographics, specific specialty pharmaceutical spend, trend, utilization mix and patterns for effective financial forecasting and medication management.

Unfortunately for payers, most specialty pharmacy plans do NOT have the full picture on payer’s specialty pharmaceutical spend under their prescription retail/mail order benefit or their medical benefit.

SBG will develop a specialty drug strategy that is appropriate for your organization.

We are experts in:

Comprehensive Reporting
Specialty pharmacy spend is generally under-reported, both under the prescription and the medical benefit. We deliver comprehensive reporting across both of these areas that discloses:

  • Total spend and future forecast
  • Top conditions by spend
  • Trends

Critical Benchmarking
Because specialty pharmacy targets a niche population with rare conditions, it is important to understand norms, variances and best practice to manage specialty pharmacy service effectively. We provide the following benchmarks:

  • Specialty Pharmacy Spend
  • Specialty Medication Definitions and Lists
  • Specialty Pharmacy Contract Terms, Conditions, Services, and Rates
  • Specialty Pharmacy Discounts (including overall effective rates)

Best-in-Class Formulary Design and Rebate Contracting
We deliver specialty pharmacy rebate solutions across the medical and pharmacy benefits. This includes direct contracts between health plans and pharmaceutical companies.

Unbiased Program Evaluation
We provide unbiased evaluations of specialty pharmacy management approaches, including comparison to industry best practices, to optimize the effectiveness of programs and prevent unintended consequences across the medical and pharmacy benefits.

Program evaluations include:

  • Formulary Management and Coverage Policies including:
    • Medication evaluations and decision making processes
    • Alignment and gaps across the medical and pharmacy benefits
  • Claims adjudication edits
  • Care Management
  • Site of Service Optimization
  • Provider reimbursement strategies

Specialty Pharmacy Procurement and Contracting
We know:

  • The right questions to ask
  • The right definitions to use
  • The right contract language to secure
  • The right operational, performance and financial guarantees to support the underlying value of your Pharmacy program

We place the Right Controls on the Specialty Drug List.

We know how to place the right controls on the specialty drug list with regards to existing products and new-to-market products. We do this by ensuring that:

  • Your specialty list has the proper controls and medications and will only be procured from a specialty pharmacy if:  
    • Specialized handling or services are required
    • The medication has a lower cost through specialty pharmacies

Market Analysis and Industry Insight
We deliver market analyses to identify industry best practices with specialty pharmaceuticals. This includes:

  • Pharmaceutical pipeline
  • Benefit, formulary, utilization management and rebate contracting approaches
  • Preferred site of care models (“Site of Care Optimization”)
  • Provider payment strategies
  • Projected spend


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