Stepping Stones: Tips for Specialty Pharmacy Payer Contracting

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Stepping Stones: Tips for Specialty Pharmacy Payer Contracting

by Jerry Buller


Several misconceptions abound in the market today about payer contracting for health system specialty pharmacy services. I’ve recently heard the following statements (or variations of them) from many health system pharmacy leaders:

  • “It’s impossible to get health plan access – they have no incentive to let you into their network.”
  • “Consultants or service providers can guarantee access to health plan networks. They do it all the time and it is not a big deal for them.”
  • “Once you’re accredited, the process is smooth.”

None of these statements are accurate. It is definitely possible for health systems to have success with specialty pharmacy payer contracting. Accreditation is not a silver bullet, and no one but the health plans themselves can guarantee or grant access to plan members.

Health system specialty pharmacy leaders need to drive payor network strategies as system initiatives, not pharmacy programs.  These strategies must include well-defined, data-driven, and continuously-executed plans. They also need to involve health system senior leadership, managed care contracting, and physicians to gain engagement of senior health plan officials.

To prepare for health plan access discussions, I would advise the following steps:

  • Target your efforts: Just like medical benefit discussions, don’t treat all plans the same. Inventory and prioritize your health plan relationships based on data from your EMR and billing systems to determine potential impact. Alongside that effort, understand where your executive team has strong health plan relationships or where you have leverage based on risk-based contracts or shared-savings populations.
  • Build a baseline: Use data to demonstrate how patients’ outcomes are improved when using your specialty pharmacy program versus health plan mandated services. Industry data suggests your services will outperform other options, driving down overall cost of care.
  • Educate your team: Although the basic tenets are the same, it’s important to note that pharmacy contracting can be very different from negotiating and working with the medical benefit. Most managed care teams in health systems will need to be educated on the nuances associated with contracting with PBMs and on the specialty pharmacy benefit before a strategy can be executed.
  • Gain alignment internally: Make sure you integrate specialty pharmacy into your organization’s broader strategy with each health plan. Understand the potential trade-offs you’ll need to make to secure access, such as decreased reimbursement for certain specialty drugs or increased operational performance standards. Know how you will measure and report the benefits the health plan will recognize as a result of your specialty pharmacy services. Make specialty pharmacy a key service line and strategy for your health system – we see health systems fail repeatedly when this remains a pharmacy-only discussion.

Health plan network access requires patience, internal alignment, methodical execution, and strong data. It is also a good reason to seek help from a partner organization like Trellis Rx to support your program growth. Read our recent article for additional insights about creating partnerships with payors and contact us if you’d like to discuss more!


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