Specialty Pharmaceuticals in the United States: Changing Patterns of Distribution and Reimbursement

Table of Contents

• Executive Summary
  • Strategic Considerations
  • Stakeholder Implications
• Introduction
• Specialty Pharmacy
  • Evolution of Specialty Pharmacy
  • Services Offered
• Coverage of Specialty Pharmaceuticals
  • Commercial Insurance
    • Medical Benefit
    • Pharmacy Benefit
  • Medicare
    • Medicare Part B
• The Medicare Competitive Acquisition Program
  • Medicare Part D
• Outlook and Implications for Stakeholders

Tables

• 1. Ownership of Leading Specialty Pharmacy Companies
• 2. Express Scripts’ Coverage of Specialty Drugs

Figures

• 1. Private Health Plans’ Average Reimbursement Rates for Specialty Drugs, Fall 2004 and 2005
• 2. Percentage of Covered Workers in Formularies of Various Structures, 2000-2006
• 3. Percentage of Covered Workers Required to Pay Copayments and/or Coinsurance by Formulary Tier, 2006
• 4. Evolution of Mean Patient Coinsurance Rates for Generics, Preferred Branded Medicines, Nonpreferred Branded Medicines, and Fourth-Tier Drugs, 2000-2006