Using Plan Design to Improve Outcomes

Hemophilia and Bleeding Disorders Toolkit

Benefit Plan Design: Using Plan Design to Improve Outcomes

Most clotting factor and substitution therapy is dispensed through specialty pharmacy networks, as well as home care pharmacies and other specialty pharmacy providers, including HTCs. For employers, however, there is often a lack of awareness and knowledge of HTCs. As a result, only 40% of clotting factor and substitution therapy is dispensed through HTC specialty pharmacies.
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Employers should work with their vendor partners and/or specialty pharmacy to identify:

  • How clotting factor and substitution therapy procurement and administration are billed under medical and/or pharmacy benefits; this is important for tracking utilization and claims experience to monitor program effectiveness. If a specialty drug carve-out approach is used and hemophilia medications are linked to that, a larger component of the cost will show up in the pharmacy benefit claims.
  • Which specialty pharmacy network strategy is in place (exclusive, open); knowing this will help evaluate whether other strategies should be considered to better manage quality and the cost of care.
  • If performance guarantees are in place to ensure patients receive medications in a timely manner. Delays in getting medication can lead to increased costs and poor outcomes.
  • Whether contracted specialty pharmacies dispensing hemophilia clotting factor adhere to MASAC #188 guidelines; these guidelines create a standard for pharmacy care and service when dispensing to members with hemophilia.
  • If a co-pay accumulator adjustor program has been deployed; accumulator programs are not recommended for use with high-cost/high-value medications which have no generic equivalents (doing so may have unintended, costly consequences such as a patient not filling their prescription or taking the full amount).
  • Which type of specialty pharmacy providers are contracted (evaluate the services provided by each):
    • PBM/commercial specialty pharmacy
    • HTC integrated specialty pharmacy
    • Home care company