Specialty Pharmacy Solution

Expanding Lab Insights to Specialty Pharmacy

Specialty Pharmacy Trends

Specialty_Pharmacy_Trends Growth 11.8% Specialty Rx drug spend grew 11.8% last year and just 3 categories account for ²/₃ of that growth.1 > 50% Drug Costs >50%of total drug costs are for specialty medications even though specialty constitutes just 2% of prescriptions. 2 75% In Development 75% of “in development” drugs fall in the specialty category, and the number of new drugs approved each year is up 60% in the last decade. 3, 4
  • Hospitals and physician groups have incorporated specialty pharmacy into their business models with more than 90% of large hospitals providing specialty pharmacy services5
  • Oncologists make a 6% mark-up on dispensing chemotherapy medication, and a growing number of medical specialties are following suit5

Managing specialty pharmacy claims through the medical benefit remains a challenge

0 %

of specialty pharmacy costs are paid under the medical benefit3

Billing errors and quality issues can impact the health and wallets of your members

Billing for medical specialty pharmacy is complicated and prone to a variety of billing errors and clinical quality issues that include:

  • Unapproved off-label use
  • Dosing and frequency-of-administration errors 
  • Overbilling of medication waste
  • Age-inappropriate treatment
Post payment review is inefficient and leaves savings on the table for you and your members.
  • A prepayment model is optimal, ensuring payment consistent with policy prior to payment being disbursed.
Avalon has adapted its proven automated policy enforcement lab claims editing system to apply a health plan’s medical specialty pharmacy clinical and administrative policies in real-time.

The Avalon Process

Group

Health Plan Adjudicates Medical Claims

Avalon integrates with health plan claims systems – one integration supports both lab and specialty pharmacy solutions

Avalon Applies Policy-Based Edits to Claims

Lab and specialty pharmacy claims are passed to Avalon where proprietary edits are applied, enforcing plan policies (with real-time response)

Real-Time Response Informs Claim Payment

Reimbursement is appropriately adjusted for ineligible billed services generating cost avoidance for the health plan

Avalon Specialty Pharmacy Solutions

  • Can help you identify the medical benefit claims appropriate for payment consistent with policy while preventing payment for unnecessary or wasteful drug administration
  • Requires no incremental health plan IT support for current LBM clients
  • Ensures payment consistent with the appropriate science and standards of care that align with your member’s benefits
  1. BenefitsPRO. August 13, 2021. Scott Woolridge. https://www.benefitspro.com/2021/08/13/specialty-drug-trend-moderated-in-2020-but-is-likely-to-regain-upward-momentum/
  2. https://www.biopharmadive.com/press-release/20210721-top-tech-predictions-for-the-future-of-speciality-pharmacy/
  3. CVS Health 2018 Drug Trend Report. https://payorsolutions.cvshealth.com/insights/2018-drug-trend-report
  4. https://www.cbo.gov/publication/57126
  5. https://www.ajmc.com/view/unraveling-the-growing-influence-of-consolidation-340b-and-industry-in-specialty-pharmacy

Don't leave savings on the table for your plan and your members! Contact Avalon today.

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