Healthcare employer reduces specialty drug spend 38% through biosimilar and site-of-care strategy
Case study by Corry Hull, REBC®, CSFS®
38%
Specialty drug spend reduction
52%→34%
Specialty as % of total Rx
3
Biologics converted to biosimilars
$420K
Annual specialty savings
The Challenge
A 650-life healthcare organization had specialty drug costs representing 52% of total pharmacy spend — well above the 40% benchmark. Three members were on biologics with no biosimilar conversion protocol. Specialty drugs were being dispensed at hospital outpatient pharmacies at inflated rates.
The Approach
A specialty drug management protocol was implemented including biosimilar step therapy for three high-cost biologics, mandatory specialty pharmacy carve-out, and site-of-care redirection away from hospital outpatient settings. A clinical pharmacist review was added for all new specialty drug authorizations.
Note: This case study is a composite of multiple employer engagements. Specialty drug cost data is from PBM claims reports. Biosimilar conversion rates reflect actual formulary changes. Sources: PBM specialty drug utilization reports; biosimilar pricing benchmarks; site-of-care cost differential analysis.
Methodology & Verification▾
Baseline
Specialty drug spend in the 12 months prior to protocol implementation.
Intervention
Biosimilar step therapy, specialty pharmacy carve-out, site-of-care redirection, clinical pharmacist review.
Measurement period
12 months post-implementation.
Savings methodology
Savings = (baseline specialty spend) minus (post-intervention specialty spend). Biosimilar savings calculated from WAC differential.
What was excluded
Clinical pharmacist program costs and PBM implementation fees excluded.
Employer size
650 benefit-eligible employees; ~580 enrolled in medical with pharmacy benefit.
Funding type
Self-funded with carved-out PBM.
Source / verification
Specialty spend verified against PBM quarterly utilization reports and plan financial statements.