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

of specialty pharmacy costs are paid under the medical benefit3

0 %
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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