Using Plan Design to Improve Outcomes

Hemophilia and Bleeding Disorders Toolkit

Benefit Plan Design: Using Plan Design to Improve Outcomes

Clotting factor is manufactured and sold directly to PBMs, their wholly-owned specialty pharmacies and to Hemophilia Treatment Center specialty pharmacies. Most clotting factor is dispensed through exclusive specialty pharmacy networks, with the remainder dispensed through 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 20% - 30% of clotting factor is dispensed through HTC specialty pharmacies.

Employers should work with their medical claims administrator and PBM, and/or the appropriate point of contact for specialty pharmacy network benefit design to identify:

  • How clotting factor procurement and administration are billed under medical and/or pharmacy benefits; this is important for tracking utilization and claims experience to monitor program effectiveness
  • 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
  • Whether contracted specialty pharmacies dispensing hemophilia clotting factor products adhere to MASAC #188 guidelines; these guidelines create a standard for pharmacy care and service when dispensing to members with hemophilia
  • 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
  • If a co-pay accumulator adjustor program has been deployed; accumulator programs are not recommended for use with high cost/high value drugs which have no generic equivalents (doing so may have unintended, costly consequences)

If a specialty drug carve-out approach is used and hemophilia drugs are linked to that, a larger component of the drug cost will show up in the prescription drug benefit claims.