OBJECTIVES : A better understanding of health plan management of specialty pharmacy (SP), SP products and biosimilars.

METHODS : Online survey of health plan exec on: roles+plan information, specialty pharmacies and specialty pharmaceuticals, expected biosimilar coverage/restrictions/copays. Results were compared with prior surveys (changes > 2% reported).

RESULTS : Survey completed by 85 respondents. 42.9% were senior officers, 13.1% regional, 8.3% payor specific, 1.2% therapeutic area specific. 36.9% worked for health plans, 13.1% PBMs, 9.5% IDNs, 2.4% PPOs/IPAs, 1.2% Government. Plans were National=29.9%,Regional=24.7% or Local=22.1% and cover multiple member types: commercial (58.6%=FFS,77.8%=HMO/PPO), Medicaid (Traditional=27.8%,HMO/PPO=72.3%), Medicare (71%,PDP-only=51%), Employer/Self-funded=79% and IDN (43.6%,340B Qualified=43.8%). 45.6% reported the plan's PBM as their SP provider and providers were restricted by 58%↓23% with plans restricting products: 58% to those under contract, 11.6% for those available through multiple SPs, 10.1% allow any SP handling a product, and 4.4% carving out their SPs. Compared with last year, providers shifted approximately 6% from independents to internally provided and currently 45.6% are PBM-owned, 38.2% health plan-owned, 25% independent and 13.2% hospital/IDN-owned. SP products continue to move from fixed to %copays with more plans determining by group+benefit design. Plans covered clinician-administered products under the medical benefit (36.8%↓7.3%), 2.9% under the pharmacy benefit the remainder used price+plan design. Biosimilar use expected for all reference product indications 58.8%↓5.7%, 31.4%↓13.5% will restrict to approved indications, and 9.8% will use indication as the basis for copay. 10%↓15% expect the biosimilar to be the only product available, copays are expected to be discounted off the innovator 58%↓10.1%, and 32%↓4.9% to vary based on approval timing. Biosimilar education provided through: different copays=64.7%, prescriber+patient mailings (76.5%↓4.2%+58.8%), prescriber+patient calls (51%↓10.6%+27.5%↑4.1%). Expected biosimilars savings: 66%↑20.9% expect 20% 5 years from now.

CONCLUSIONS : Costs associated with specialty pharmacies and specialty pharmacy products have shifted and are expected to grow with some relief coming from biosimilars.