Payers consider audit process for specialty

Key Points

PHARMACY AUDITS-which provide checks and balances-are beginning to spread into the practice of specialty pharmacy, where high costs are commanding attention.

"For these reasons, along with efforts to meet accreditation standards, stakeholders believe that specialty pharmacy may already be more diligent," he says.

This year's Specialty Drug Benefit Report from the Pharmacy Benefit Management Institute shows that the most common management strategies are: prior authorization under the pharmacy benefit (91.7%); required use of contracted specialty pharmacy (76.7%); step therapy (73.3%); and use of preferred products for certain therapy classes (73.3%).

Stern predicts that specialty pharmacy audits will become more frequent but will likely follow existing audit criteria. Payers should address appropriate use (prescribed for the right indication), compliance, correct dosage and utilization criteria developed by national organizations, such as the National Cancer Institute or the National Comprehensive Cancer Care Network.

"Although specialty pharmacies are held to more stringent requirements, the audits do not differ dramatically from those applied to traditional pharmacies," says Robert Galle, head of Aetna's pharmacy management program.

Even so, Stern says the trend toward more specialty pharmacy audits points to an increase in coverage and benefits and stricter contract controls.

"The rationale for an audit will not disappear, so specialty pharmacy needs to provide valid information, and plans should look more closely at these drugs because of their high expense," Stern says.

Mark Boesen, PharmD, legal specialist, Quarles & Brady LLP in Phoenix, sees more activity in the specialty pharmacy space than in traditional pharmacy because of its high spend. He also attributes costs to the advent of personalized medicine and to the development of oral drugs used to treat patients at home rather than at a care site. Usually the oral therapies fall under the pharmacy rather than the medical benefit.

"Health insurers, pharmacy benefits managers and auditors will often focus their efforts on high dollar-claims to assure the pharmacy is complying with contractual agreements, as well as state and federal laws associated with the delivery of pharmacy care," Boesen says.

John Helfrich, director of pharmacy operations for OncologyRx Care Advantage, a specialty pharmacy division of McKesson Specialty Health, says that Part D increased government regulation and new technology drives plans' focus on managing specialty pharmacy. Plans must be able to spot discrepancies in claims, he says.