Representatives from the National Pharmaceutical Council (NPC) and the Pharmaceutical Strategies Group (PSG) presented the results of a nationwide plan sponsor survey at the 2022 Asembia Specialty Pharmacy Summit in Las Vegas, Nevada.

The report, “Trends in specialty drug design‘, conducted by PSG in late 2021, included the results of a survey of 171 benefits leaders, representing approximately 41.1 million lives covered. All participants offered specialty drug coverage for pharmacy and medical benefits, while 80% of the surveyed population self-insured for both pharmaceutical and medical benefits, explained Sharon Phares, PhD, MPH, Chief Scientific Officer of NPC and author of the report.

When it comes to trends and plan sponsor concerns in this area, “employers have a ton of competing priorities,” said Michael Lonergan, president of medication management solutions at PSG. Employers also want members to have access to drugs, and they want to pay for those drugs and make sure they work, Lonergan said.

Concerns about misuse and waste are at the heart of employers’ concerns, but often accessing information about these measures can be difficult. Employers “want to be able to synthesize this information and help them make informed decisions about their benefit design or overall program management strategies,” Lonergan added.

Survey results revealed an increasing use of high-deductible health plans (HDHPs), with 36% of respondents saying their most important plan for the 2021 benefit year was an HDHP.

“It really becomes a balancing act,” said panelist Renee Rayburg, vice president of specialist clinical advice at PSG, who said employers want to offer good benefits to recruit and retain talent, but need to find ways to simultaneously contain the costs.

“There’s a bit of irony – they’re worried about reducing out-of-pocket expenses for patients, but their benefit designs don’t necessarily reflect that,” Lonergan added.

With respect to specialty drugs, Phares explained that the most commonly reported tool is cost sharing. Additionally, in 2021, 51% of plan sponsors reported using coinsurance for specialty drug cost sharing, marking the first time this metric exceeded 50%. This is a significant change from the previous use of a flat dollar copayment.

Coinsurance percentages varied slightly depending on the benefit under which the specialty drug is covered, she noted.

Additionally, results revealed that more than 90% of plan sponsors used pre-authorization step therapy and quantity limits.

“From an employer perspective, I think they’re really committed to making sure there’s a strong clinical prior clearance program,” noted panelist Tracy Spencer, senior vice president and chief the national practice of employers, advice to employers, to the PSG.

Being able to accurately track and report pre-approval approval and denial rates is also important for these sponsors. Two-thirds of respondents said they could access this data, Phares said. Rates are helpful in determining if utilization management and prior authorizations are working, and can also inform appeal actions to ensure drugs are used appropriately.

Being aware of this information will improve long-term decision-making, Spencer said. Additionally, since new drugs are continually coming to market and may be more effective than older drugs, sponsors want to know if their investments are paying off or if they need to switch to new therapies.

“That translates to a better patient experience and a better clinical experience,” Rayburg said.

The results also showed that 12% of plans entrust utilization management to their pharmaceutical benefit managers (PBMs), while 13% plan to do the same, according to Phares.

Half of employers were aware of new-to-market form blocks or form restrictions used by PBMs to restrict coverage and reimbursement for new products for some time, she said.

However, the lack of consistent industry wording in these restrictions presents a challenge for employers. While drugs are applied during the lock-in period, sometimes at a very high constant rate, “when the claim is paid, they are not paid at a rate that you would expect and then they are excluded from discounts,” said Lonergan, noting that this area provides another opportunity for employer education.

Other survey results showed that only 25% of participants knew enough about biomarker diagnostic tests; 22% had never heard of this term before. As precision medicine becomes more mainstream, stronger knowledge of these services will be warranted in order to provide coverage options for testing, panelists said.

Citing the example of limited CMS coverage of Biogen’s Alzheimer’s drug aducanumab, situations like these put employers in the difficult positions of balancing the clinical benefits of new drugs with the cost.

At the time of approval “many [employers] looked more to larger organizations and to CMS to see what they were doing. So there was this hesitation,” Rayburg explained. This factor was complicated by the fact that the drug was initially approved for a large population and then later restricted to a smaller number of patients.

Overall, employers are more conservative in similar situations and really seek out more information to make short- and long-term coverage decisions, Lonergan said.

For this information about the Alzheimer’s drug, employers turned primarily to PBM teams and benefits consultants, according to the survey results.

Noting that everyone in this process likely has biases — from providers to payers to manufacturers — Lonergan stressed the importance for employers to gather clinical data and results from multiple sources.