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Tips from the Specialty Pharmacy Management Checklist

Are you struggling with managing specialty pharmacy in plan design? Our new Specialty Pharmacy Management Checklist provides detailed tips for staying ahead of the curve – from utilization management to reporting and accountability to employee education.

Here are some tips from the checklist:

Specialty Pharmacy Checklist

Practice active utilization management (UM) by building medical necessity/eligibility criteria into your UM programs. A comprehensive UM program may consist of:

  • A prior authorization (PA) strategy that incorporates medical eligibility criteria.  
  • A step therapy program encouraging the use of available generic medications before initiation of biologics or expensive brand-name drugs.
  • Quantity limits to ensure proper dosage, patient tolerance and adherence.
  • Exclusions or “exclude at launch” strategies.

It is important to monitor the performance of PAs and other UM edits over time. Request regular reporting related to PA approval/denial rates and independently validate the performance of your UM programs periodically via an audit or technical review. 

Plan Design:

Consider adding an additional specialty drug tier or two (preferred and non-preferred) to your design. Keep in mind the total out-of-pocket burden for patients on these high cost drugs, particularly in a CDHP.

Distribution and Pricing:

Try to maximize savings by working with a network of specialty pharmacies or by channeling patients through the most cost effective specialty pharmacy network. Ask questions to determine and understand how the distribution is actually being paid for to ensure that you are not paying for something that drug manufacturers might already be paying for. Conduct a periodic competitive assessment and renegotiation of your specialty pricing arrangement. PBMs offer multiple specialty drug price lists to their clients, and these price points are often subject to competitive pressure. Specialty pricing should be benchmarked at least every two years; this can be done as part of a formal Market Check process, if the contract allows for it.


MEMBERS—see the full checklist for more detailed tips on how to properly manage specialty Rx in plan design.