Specialty Pharmacy Carve-Out Benefits
- Better pricing: Carve-out pharmacies often offer lower acquisition costs than PBM-owned pharmacies
- Clinical support: Dedicated clinical pharmacists who specialize in specific conditions
- Adherence management: Proactive outreach to improve medication adherence
- Patient services: Injection training, side effect management, and patient support programs
- Data access: Better data on specialty drug utilization and outcomes
- Manufacturer programs: Access to manufacturer patient assistance and co-pay programs
Carve-Out Pharmacy Options
Specialty pharmacy carve-out options include: (1) independent specialty pharmacies (Diplomat, Amber Pharmacy); (2) hospital-based specialty pharmacies; (3) manufacturer-affiliated specialty pharmacies; and (4) employer-sponsored specialty pharmacy programs. Each option has different pricing, clinical capabilities, and administrative requirements.
Carve-Out Compliance
IQ Insight
Specialty pharmacy carve-out compliance is critical. If the PBM routes specialty prescriptions through its own specialty pharmacy instead of the carve-out pharmacy, the employer loses the carve-out savings. Audit specialty drug claims quarterly to verify that specialty drugs are being dispensed through the carve-out pharmacy. Carve-out compliance violations are a common finding in PBM audits.