Managing High-Cost Specialty Medications: The MaxCare Approach

Managing High-Cost Specialty Medications: The MaxCare Approach

In recent years, the rising cost of specialty medications has become a significant concern for both patients and healthcare payers. These high-cost drugs, often used to treat complex and chronic conditions, can strain healthcare budgets and put a financial burden on patients. However, Pharmacy Benefit Managers (PBMs) have emerged as vital players in managing the costs associated with specialty medications. With their comprehensive medication management services and innovative strategies, PBMs play a crucial role in ensuring that patients have access to the medications they need while controlling costs. Let’s explore the strategies PBMs employ to manage high-cost specialty medications and highlight the importance of their involvement in cost management.

The Growing Challenge of High-Cost Specialty Drugs

High-cost specialty medications are a rapidly expanding category of pharmaceuticals, characterized by their complex management requirements and steep price tags. These drugs, often used for the treatment of chronic or life-threatening conditions like cancer, autoimmune diseases, and rare genetic disorders, are increasingly at the center of discussions about health care costs, drug pricing, and the management of medical benefits.

The spend on specialty medications has been trending upward, becoming a significant component of overall health care costs. This is attributable to several factors, including advancements in precision medicine, the emergence of gene therapies, and an increase in the number of conditions that these drugs can treat. While these developments are undoubtedly beneficial from a population health perspective, they present growing challenges in managing costs, particularly in a hospital setting, where patients often receive infusion treatments.

For many patients and their medical plans, the high cost and utilization of specialty medications can create financial strain. This is where pharmacy benefit solutions can play a pivotal role. These solutions overview a comprehensive approach to managing the cost of specialty drugs, from the point of prescribing to patient administration. Strategies may involve focusing on drug management, including the selection of lower-cost alternatives, appropriate drug utilization, and optimizing the sites of care, such as shifting from a hospital setting to a physician’s office or even home infusion when appropriate.

The management strategies employed often extend to retail pharmacies, where a significant portion of the spend on specialty drugs occurs. By implementing a robust management program, these pharmacies can assist in controlling specialty drug prices while ensuring the delivery of high-quality patient care.

The complexity of these drugs requires a strategic and integrated management approach that considers every aspect of care, from drug trends and pricing to plan design and benefits solutions. Comprehensive programs can help manage these high-cost specialty medications, which includes not only cost management but also aspects of behavioral health, necessary for patient adherence and overall treatment success.

While the focus on cost is paramount, it’s equally crucial to ensure that the patient receives the most appropriate therapy for their condition. This is a cornerstone of precision medicine – the practice of tailoring treatment to an individual’s specific genetic makeup, environment, and lifestyle.

Brokers and consultants can provide significant value by educating clients about the challenges associated with high-cost specialty medications, presenting various management strategies, and providing tailored pharmacy benefit solutions. Controlling health care costs, particularly those related to high-cost specialty drugs, requires a multidisciplinary approach that combines medical and pharmacy expertise, along with a deep understanding of population health and benefits design.

Why Prescription Management is an Important Cost Control

Prescription management plays a critical role in controlling healthcare costs, particularly when it comes to specialty medications. PBMs are well-equipped to handle this task due to their expertise in managing drug utilization, formulary management, and benefit design. By implementing effective prescription management services, PBMs can help identify appropriate treatment options, optimize drug utilization, and control costs. 

Strategies Employed by PBMs in Managing Specialty Medications

PBMs employ a range of strategies to manage high-cost specialty medications effectively. It is important to note that not all PBMs take the same approach; however, the following strategies are commonly used:

Formulary Management

PBMs work closely with plan sponsors to develop formularies that promote cost-effective medication options. By carefully evaluating the clinical and economic value of different drugs, PBMs can guide physicians and patients towards the most appropriate and cost-effective therapies. This approach helps control costs by prioritizing medications with comparable efficacy and safety profiles but varying price points.

Utilization Management

PBMs implement utilization management techniques to ensure the appropriate use of specialty medications. These techniques may include prior authorizations, step therapy protocols, and quantity limits. By requiring documentation of medical necessity and encouraging stepwise treatment approaches, PBMs can minimize unnecessary utilization and control costs without compromising patient care.

Benefit Design

PBMs collaborate with plan sponsors to design benefit plans that promote cost-effective medication use. By aligning medical and pharmacy benefits and incentivizing the use of preferred medications, PBMs can drive cost savings. Benefit designs that encourage the use of generics or lower-cost alternatives can significantly reduce specialty drug spend while ensuring patients have access to necessary therapies.

Digital Health Solutions

PBMs are increasingly leveraging digital health tools to enhance medication management and patient engagement. These technologies, such as mobile applications and online portals, enable patients to access educational resources, medication reminders, and adherence support. By promoting self-management and empowering patients to take an active role in their healthcare, PBMs can improve outcomes and reduce costs associated with specialty medication non-adherence.

Alternative Funding

PBMs explore alternative funding mechanisms to manage specialty drug costs. This may involve negotiating value-based contracts with pharmaceutical manufacturers, where reimbursement is tied to patient outcomes. By aligning financial incentives with treatment effectiveness, PBMs can ensure that the cost of specialty drugs is justified by their therapeutic value.

MaxCare: A Layered Approach to Specialty Medication Management

As we continue to grapple with the challenges posed by high-cost specialty medications, comprehensive and innovative management approaches will be integral in optimizing care quality, managing costs, and enhancing the value of the medical benefit. The future of health care hinges on the ability to provide accessible, affordable, and high-quality care, and the strategic management of high-cost specialty medications plays a significant role in realizing this objective.

One example of a PBM’s approach to managing high-cost specialty medications is MaxCare’s comprehensive medication management services. MaxCare employs a layered approach to ensure cost-effective medication use:

  • Medication Assessment: MaxCare’s clinical experts thoroughly assess each medication to ensure that it is the right drug at the right price for the right patient. By considering both clinical efficacy and cost-effectiveness, MaxCare helps guide towards the most appropriate treatment options.
  • Coupon Assistance: MaxCare identifies any available coupon assistance programs for high-cost brand and specialty medications. These programs can help offset the out-of-pocket costs for patients, making treatment more affordable while still maintaining the desired therapeutic outcomes.
  • Generic Utilization: MaxCare actively promotes the use of lower-cost generic medications when they are equally effective as their brand-name counterparts. By encouraging the use of cost-effective generics, MaxCare helps control costs while ensuring patients receive high-quality care.
  • Combination Medication Evaluation: MaxCare evaluates high-cost combination medications to identify opportunities for cost savings. If equally effective over-the-counter medications are available, MaxCare may remove the high-cost combination medications from the formulary, reducing unnecessary expenses.
  • Data Analysis and Reporting: MaxCare utilizes advanced data analytics to identify trends and patterns in specialty drug utilization. By analyzing prescription data, MaxCare can identify opportunities for further cost optimization and inform decision-making for plan sponsors.


Through our comprehensive medication management services and innovative strategies, MaxCare helps control costs while ensuring that patients have access to the medications they need. By implementing strategies such as formulary management, utilization management, site of care optimization, benefit design, specialty pharmacy management, and digital health solutions, we drive cost savings and promote value-based care. MaxCare’s layered approach exemplifies our commitment to managing specialty pharmacy costs effectively by ensuring the right drug at the right price for the right patient, utilizing coupon assistance, encouraging generic utilization, evaluating high-cost combination medications, and leveraging data analysis for informed decision-making.

In today’s healthcare landscape, managing the cost of specialty medications is crucial for achieving health equity and controlling healthcare costs. MaxCare will continue to play a vital role in this endeavor, providing comprehensive solutions to optimize medication management, improve patient outcomes, and ensure the financial sustainability of the healthcare system.

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