Only 1% to 2% of the American public uses specialty drugs, yet they account for approximately 38% of total drug expenditures.
When health plans allow hospitals or pharmacy benefit management (PBM) companies to review authorizations for specialty drugs being dispensed by their own pharmacy, no independent review process is involved. The same is true when medical providers submit specialty drug prescriptions as claims under the medical plan rather than the prescription drug benefit plan.
To help self-funded employer groups avoid these potential conflicts, Diversified’s Pharmasense program provides prior authorization, or pre-certification, of all specialty drug prescriptions. By considering several factors, such as the patient’s condition and clinical evidence related to the drug, the Pharmasense program can deliver tremendous cost savings and quality outcomes for the patient.