what are examples of specialty medications with medicare

Examples of Drugs Often Coordinated by Specialty Pharmacies: Actemra (tocilizumab) - rheumatoid arthritis Afinitor

(everolimus) - cancer; kidney, breast cancer, or brain tumor

Full Answer

What drugs are covered by Medicare drug plans?

Most Medicare drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage.

What are some examples of specialty pharmacy drugs?

Examples of Drugs Often Coordinated by Specialty Pharmacies: Actemra (tocilizumab) - rheumatoid arthritis Afinitor (everolimus) - cancer; kidney, breast cancer, or brain tumor Atripla (efavirenz, emtricitabine, and tenofovir) - HIV Aubagio (teriflunomaide) - multiple sclerosis

What are the different types of prescription drugs?

Prescription drugs (outpatient) 1 Drugs used with an item of durable medical equipment. ... 2 Injectable and infused drugs. ... 3 Oral End-Stage Renal Disease (ESRD) drugs: Medicare helps pay for some oral ESRD drugs if the same drug is available in injectable form and the drug is covered under the ... More items...

What is a specialty drug?

Specialty drugs are complex and/or “high touch” medications that are prescribed for people with complex, chronic, or rare conditions like cancer, multiple sclerosis, hepatitis C, HIV/AIDS, and rheumatoid arthritis, among others.

What are Medicare specialty drugs?

Specialty drugs* are high cost prescription medications designed for complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. Specialty drugs may be oral or given by injection or infusion. Some may require special handling and administration.

What is an example of a specialty medication?

Specialty drugs are often biologics—"drugs derived from living cells" that are injectable or infused (although some are oral medications). They are used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V. psoriasis, inflammatory bowel disease and hepatitis C.

What are specialty tier drugs?

Specialty tier drugs—defined by Medicare as drugs that cost more than $670 per month in 2019—are a particular concern for Part D enrollees in this context.

What is considered specialty pharmacy?

NASP defines specialty pharmacy as “a state-licensed pharmacy that solely or largely provides only medications for people with serious health conditions requiring complex therapies.

What is a non preferred specialty drug?

What are non-preferred brand-name drugs? These are brand-name drugs that are not included on the plan's formulary (list of preferred prescription drugs). Non-preferred brand-name drugs have higher coinsurance than preferred brand-name drugs.

Are there generic specialty drugs?

Prescription drugs can carry many labels, such as — brand name, generic and specialty. They are all designed to treat specific medical conditions, work in different ways or offer more affordable options.

What is a Tier 5 specialty drug?

Tier 5 - Nonpreferred Specialty: In Tier 5 are nonpreferred specialty drugs that likely have a more cost-effective generic or preferred alternative available. Tier 5 has the highest copayment for specialty drugs. In some cases, they may not be covered.

Is Humalog a specialty drug?

Specialty drugs are a relatively small part of total prescriptions filled at the pharmacy, but they are a dramatically increasing part of total prescription spending....The 25 Drugs That Cost Health Plans the Most in 2014.ProductHumalogCondition TreatedDiabetesTotal spending273,236,112Number of prescriptions432,16324 more columns•Jul 6, 2016

Who is the largest specialty pharmacy?

Fein noted that the three largest PBMs in the United States — CVS Caremark, OptumRx, and Express Scripts — now manage more than 75% of prescription claims. The PBMs have moved into ownership of specialty pharmacies because most manufacturers launch their specialty drugs in narrow networks, Fein explained.

What are the 8 specialty areas of pharmacy?

Currently, the Board of Pharmacy Specialties (BPS) recognizes eight specialty areas of pharmacy:Ambulatory Care.Critical Care Pharmacy.Nuclear Pharmacy.Nutrition Support Pharmacy.Oncology Pharmacy.Pediatric Pharmacy.Pharmacotherapy.Psychiatric Pharmacy.

What is the difference between a regular pharmacy and a specialty pharmacy?

While retail pharmacies are for short-term illness, specialty pharmacies work with patients and physicians to provide medications for chronic and more severe illnesses. Specialty pharmacies serve patients with serious health conditions who require complex treatment therapies.

What is CVS Caremark specialty pharmacy?

Our specialty pharmacy. CVS Specialty provides medication and support for patients with complex conditions, like rheumatoid arthritis, multiple sclerosis or cancer. Go to CVSspecialty.com. For patients who take specialty medications For health care providers. For patients who take specialty medications.

Buy-and-bill (Medicare Part B) 1

ASP, average sales price; BI, benefits investigation; HCP, health care professional; MAPD, Medicare Advantage prescription drug plan; PA, prior authorization; PDP, prescription drug plan; SP, specialty pharmacy; WAC, wholesale acquisition cost.

Specialty pharmacy (Medicare Parts C and D) 2

ASP, average sales price; BI, benefits investigation; HCP, health care professional; MAPD, Medicare Advantage prescription drug plan; PA, prior authorization; PDP, prescription drug plan; SP, specialty pharmacy; WAC, wholesale acquisition cost.

Patient out-of-pocket (OOP) costs

Click here to learn more about the programs some manufacturers may offer to support patients.

How many drugs does Medicare cover?

All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer. The formulary might not include your specific drug. However, in most cases, a similar drug should be available.

How many prescription drugs are covered by Medicare?

Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per ...

What is formulary exception?

A formulary exception is a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule. A tiering exception is a drug plan's decision to charge a lower amount for a drug that's on its non-preferred drug tier.

What happens if you don't use a drug on Medicare?

If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money.

What does Medicare Part D cover?

All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary.

What is a tier in prescription drug coverage?

Tiers. To lower costs, many plans offering prescription drug coverage place drugs into different “. tiers. Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier. ” on their formularies. Each plan can divide its tiers in different ways.

What is a drug plan's list of covered drugs called?

A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

What is specialty medicine?

What are specialty drugs? Specialty drugs are complex and/or “high touch” medications that are prescribed for people with complex, chronic, or rare conditions like cancer, multiple sclerosis, hepatitis C, HIV/AIDS, and rheumatoid arthritis, among others. Because of their complex nature, they typically require special delivery, preparation, ...

What happens if a drug is not on the formulary?

If a drug is not on the formulary, you will have to pay the entire cost yourself, unless your doctor can convince your insurer that no other option will work for you. Insurers have a separate formulary list for specialty drugs, and you’ll need to check that list to see if your medication is included.

Can you use your usual pharmacy for specialty medications?

You may not be able to use your usual pharmacy for your specialty medication. Utilization management – Because of the high cost associated with specialty medications, insurance companies want to minimize the amount of these drugs that goes to waste.

Do you need prior authorization for a specialty?

Prior authorization – Your health plan may require your doctor or pharmacy to file prior authorization paperwork before they will cover your specialty medication. Step therapy – Your health plan may require you to show that a lower-tier medication has not worked for you before they will cover your specialty medication.

Does your health insurance cover your own medication?

However, if you administer your own medication, it will probably be covered through the prescription drug portion of your health coverage. Before you go any further, it is important that you know how the drug will be administered.

Do specialty drugs run through medical benefits?

You might not realize it, but 50% of specialty drugs actually run through medical benefits, not drug benefits. If a healthcare professional administers your specialty medication, whether at a doctor’s office, clinic, or in your home, the specialty drug will likely be covered through your medical benefits. However, if you administer your own medication, it will probably be covered through the prescription drug portion of your health coverage. Before you go any further, it is important that you know how the drug will be administered.

What is specialty medicine?

Specialty drugs typically treat chronic, complex, or rare conditions, frequently have high prices, and may require special handling or monitoring of patients. From 2010 through 2015, such drugs accounted for a growing share of new drugs introduced to the market, and they were introduced at much higher prices than nonspecialty drugs. In 2015, brand-name specialty drugs accounted for about 30 percent of total net spending on prescription drugs in both Medicare Part D and Medicaid, although they accounted for only about 1 percent of all prescriptions dispensed in each program.

What are the two types of Medicare Part D plans?

Two categories of plans participate in Medicare Part D: stand-alone prescription drug plans , which enroll beneficiaries who receive their other Medicare coverage through the traditional FFS program, and Medicare Advantage prescription drug plans. The plans compete for enrollees on the basis of premiums, benefit design, specific drugs covered, and quality of services.

Does Medicaid cover outpatient pharmacy?

(The federal subsidy amount varies across states.) Medicaid outpatient pharmacy benefits may be delivered by Medicaid FFS, wherein states directly reimburse pharmacies for prescription drugs. Alternatively, states may contract with private managed care plans to administer the drug benefits together with medical benefits. Under the Medicaid program, beneficiaries generally have low cost sharing for prescription drugs. According to CMS, the federal share of Medicaid drug spending on outpatient pharmacy benefits, net of rebates, was $21 billion in 2015.33

10. Sleep disorders

Despite low market share, this class was able to make the top 10 specialty medications easily due to the average cost per prescription of about $9000. The PMPY spend increased by 24.1%, which was influenced by an 18.5% increase in cost and 5.5% increase in utilization.

9. Hemophilia

There was a 15.4% increase in unit cost, which contributed to the rise in spend for 2015. Brand inflation for antihemophilic and clotting drugs, such as antihemophilic factor (recombinant) (Eloctate), which had a triple digit utilization and unit cost increases, also contributed to the increase.

8. Pulmonary hypertension

The 13.4% utilization increase and 4.8% unit cost increase were responsible for the increased trend by 18.1% in 2015. Utilization increased for 7 of the 10 top drugs in spend for this class. Sildenafil is still the most prescribed drug in the class, accounting for 36.4% of the market share.

7. Cystic fibrosis

The trend for this class of medications reached 53.4% in 2015. This class only consists of 10 drugs with an average cost per prescription of $6,441.27. One of the 2 most costly drugs for cystic fibrosis approved in mid-2015 is lumacaftor/ivacaftor (Orkambi), which helped drive the trend.

6. Growth deficiency

The trend for rare condition growth deficiency was 5.6% as a result of equal trend in utilization and unit cost (2.8%). For the fourth consecutive year, somatropin (Norditropin, Flexural) dominated the class and accounted for 49.1% of market share.

4. Hepatitis C

In 2014, there was a record increase in spend because of new and effective oral antiviral therapies with an expensive price tag. However, the 2015 trend was lower with a spend increase of 7%. Utilization decreased 2.2%, while there was a 9.2% increase in unit cost that was responsible for driving a majority of the change in spend.

3. Oncology

The FDA approved 10 oncology therapies in 2015, which helped increase spend 23.7%, while the increase in utilization (9.3%) and unit cost (14.4%) helped drive the trend.

What is specialty type medicine?

Specialty-type drugs have been growing rapidly over the last two decades. These drugs are FDA-approved to treat complex medical conditions and rare diseases, and are often very expensive and require special storage, preparation, and handling. They can be taken orally, injected, inhaled or given by infusion.

What is specialty pharmacy?

A specialty pharmacy is usually a subset of a larger health insurance provider, retail provider, or pharmacy benefit manager (PBM) that coordinates these services, although independent specialty pharmacies also exist . Some of the top Specialty Pharmacies in the U.S. include:

How much will the pharmaceutical market be in 2023?

IQVIA estimates the global pharmaceutical market will exceed $1.5 trillion by 2023. Over two-thirds of launches in the next 5 years will be specialty products, lifting specialty share of spending to near 50% by 2023 in most developed markets. Many of the costs shared for specialty drugs come out of a patient's pocket.

What to do if you can't afford a prescription?

If you cannot afford your medications, or have no assistance, have a frank discussion with your healthcare provider about other alternatives or options. They are always glad to offer help and advocate for you in any way possible. See the National Association of Specialty Pharmacy.

What is a specialty pharmacy care coordinator?

Your specialty pharmacy care coordinator can refer you to a financial assistant that may know of alternative ways to help you pay for your drugs; for example, through a manufacturer’s Patient Assistance Program (PAP) or a state assistance program. The Patient Advocate Foundation may be another source.

Do specialty pharmacies file insurance claims?

Specialty pharmacies will usually file your insurance claim for you and take care of the details known as “prior authorization” to help get your medication covered. They will contact the insurance company and even determine the paperwork that needs to be completed. They will work on your behalf if a claim is denied.

Do specialty drugs come out of pocket?

Many of the costs shared for specialty drugs come out of a patient's pocket. You should have the right to understand and make informed decisions about your medications -- the pros and cons -- as well as important cost issues. All of these are areas a specialty pharmacy can help educate you about; however, many patients are confused about these ...

Let us ease your administrative burdens

UnitedHealthcare offers the only Medicare plans that carry the AARP name. UnitedHealthcare and Optum® Specialty Pharmacy are part of the UnitedHealth Group® family. No specialty pharmacy services more AARP Medicare plan members than Optum Specialty Pharmacy. That service includes:

We handle prior authorizations, too

Another benefit of UnitedHealthcare and Optum Specialty Pharmacy’s connection through UnitedHealth Group is that our enhanced visibility allows us to: