Frequently Asked Questions
Consumers and Specialty Drugs
Introduction: With health care and related benefits costs always on the rise, it has never been more important for
every person at [ORGANIZATION NAME] to play their part in helping reduce costs in ways that result in better
health. Did you know that as much as 30 percent of U.S. health care dollars are spent on misuse and overuse of
services? Or that an estimated 40 percent of Americans don’t get the right care? There are many ways we can
lower costs together, and we are going to start by helping you understand why we are making certain decisions
about high-cost specialty drugs. We are committed to ensuring our employees have access to the care they need
at a cost we all can afford.

What are specialty drugs?
o They often require special handling (refrigeration) and administration (injections/infusions through
an IV).
o They are usually dispensed through the mail by a “specialty pharmacy,” not a retail pharmacy like
Walmart or Costco.
o Once used to treat rare or serious conditions like multiple sclerosis, rheumatoid arthritis, cancer,
and other conditions, more and more, new and costly drugs are being used to treat common
conditions like diabetes and high cholesterol. “Tried and true” drugs for common conditions are
available at a tiny fraction of the cost of specialty drugs, and are right for most people.
o They are expensive! Specialty drugs can cost upward of $100,000. Even though our employees
may not see that cost, we are “self-insured” which means that [ORGANIZATION NAME] actually
writes the check for the drug. We want every employee to receive the care they need — and to
avoid care they don’t.

What do you mean we are self-insured?
o [ORGANIZATION NAME] directly assumes the major cost of health insurance for our employees.
Many believe that [HEALTH PLAN] pays the bill. The truth is, the health plan simply pays the
bills with our money.

Why are specialty drugs so expensive?
o Drug makers say the high price of new drugs is related to research and development, but much of
the cost is covered by the government, employers, taxpayers, and others.
o Drug makers raise prices as much as they want, whether or not patients get better.
o As new drugs come on the market that compete with existing drugs, prices increase, rather than
decrease. (For example, the annual cost of multiple sclerosis therapies rose 500% in 10 years as
other options became available. This is the opposite of how the market normally works).
o There is low competition from other drug makers.
o Drug makers often charge what they want and raise prices, even when there is no improvement
in patient health, or increased cost to make or deliver the drug.
o They are distributed through a complex web of suppliers, all making money and adding to the
cost along the way to the patient (for example, “hubs” offer many of the same services as
specialty pharmacies, but they are paid by drug makers to get patients on drugs as soon as
possible, bypassing measures designed to ensure patients receive the right medicine at the right
price).

What happens if my doctor prescribes a specialty drug?
o Your prescription will be dispensed by a specialty pharmacy, usually through the mail, or given in
a doctor’s office or hospital outpatient setting.
o You may receive calls from the specialty pharmacy, drug maker, health plan, and/or pharmacy
benefit manager (PBM) to make sure you know how to take your prescription correctly. They will
also help you manage side effects and determine if the drug is working as it should.
o You may receive coupons to cover part or all of your cost:
o These coupons or financial assistance programs are often available when competing,
less expensive drugs are available.
o While we are used to coupons being a good thing, specialty drug coupons and programs
are not free. They raise prices for everyone.

What questions should I ask my doctor when a specialty drug is prescribed for a family member
or myself?
o Do I really need this drug?
o How much will this cost me?
o What will it cost my insurer or employer?
o Are there less expensive, safer options that may be as effective?
o How does this drug work?
o What are the risks of taking this drug?
o What are the benefits of taking this drug?
o How likely is this drug to help me?

What can I do to reduce the cost of drugs for myself and for others?
o Look at how you might be helped: Read about how effective it is, side effects, how to take it, and
what to watch out for. Check independent, neutral, trustworthy websites (e.g., fda.gov,
consumerreports.com, druginfo.nim.gov.)
o Check prices at several pharmacies by phone (website prices change often). Even if a pharmacy
is “out of network” it may be less expensive.
o Take the drug just as your doctor instructs you to do.
o Tell your doctor how the medication is working, and if you have concerns or side effects.
o Ask if there are other things you might do to treat your condition (for example, changing your diet
or exercise habits).
o If your drug is given through an IV, ask to go to the lowest-cost site (The cost of a clinic visit can
be half the cost of an outpatient hospital visit, but the medicine and care are the same).

How do I know if my drug is covered by my health plan, or how much I will pay out of my pocket?
o Check the website of your health plan or Pharmacy Benefits Manager (PBM) to see if they
provide a list of covered drugs (called a formulary).
o Call the health plan customer service number or PBM, found on your member I.D. card (you may
have a separate card for your pharmacy benefits).
o Talk to your HR or benefits department.
o Use resources as they become available (e.g., PBMs, specialty pharmacies, and others).
Fast Facts:
[ED. NOTE: You may choose to use all or some of these as part of the FAQs, or use them in your
employee communications materials.]





















For some chronic conditions, a year of treatment with a specialty drug can exceed $100,000. 1
In 2014, less than 1 percent of all prescriptions were written for specialty drugs, yet they accounted for
approximately 32 percent of total drug expenditures.2
The price of many specialty drugs continues to rise: In 2013, the average wholesale price of existing
specialty pharmaceuticals increased by over 10 percent.3
Utilization rose by 5.8 percent in 2014 because of increased use of existing drugs and the introduction of
new pharmaceuticals, for example:4
o In 1990, only 10 specialty drugs were on the market;5
o Currently, approximately 300 such drugs are on the market,6 19 of which became available in
2014 alone;7 and
o Nearly 700 specialty drugs are under development.8
Because of higher prices and increased use, spending on specialty drugs represents an increasing share
of total health care costs.9 In 2012, specialty drug spending reached $87 billion, or 3.1 percent of national
health spending in the United States.10
Current trends suggest that specialty drug spending will total $400 billion by 2020, or about 9.1 percent of
national health spending.11
The estimated number of Americans with annual drug costs greater than $50,000 increased 63 percent in
2014 (from 352,000 people to 576,000).12 Many of these patients take multiple drugs, and 92 percent use
high-priced specialty drugs.13
1 Bradford R. Hirsch, Suresh Balu, and Kevin A. Schulman, “The Impact of Specialty Pharmaceuticals as Drivers of Health Care
Costs,” Health Affairs 33, no. 10 (2014): 1714–1720, http://content.healthaffairs.org/content/33/10/1714.short.
2 Express Scripts, “Insights: U.S. Rx Spending Increased 13.1% in 2014,” http://lab.express-scripts.com/insights/industryupdates/us-rxspending-increased-13-percent-in-2014.
3 CVS/Caremark, “7 Sure Things to Help You Know Where to Go Next With Your Prescription Drug Benefit” (2014)
http://investors.cvshealth.com/~/media/Files/C/CVS-IR/reports/2014-cvs-caremark-insights-report.pdf.
4 Express Scripts, “2014 Drug Trend Report” (2015), http://lab.express-scripts.com/drug-trend-report.
5 American Journal of Managed Care, “The Growing Cost of Specialty Pharmacy—Is it Sustainable?” (2013),
http://www.ajmc.com/payerperspectives/0213/The-Growing-Cost-of-Specialty-PharmacyIs-it-Sustainable.
6 Ibid.
7 American Pharmacists Association, “Specialty Drug Approvals: Review of 2014 and a Forecast for 2015” (2015),
http://www.pharmacist.com/specialty-drug-approvals-review-2014-and-forecast-2015.
8 IMS Health, “Overview of the Specialty Drug Trend: Succeeding in the Rapidly Changing U.S. Specialty Market” (2014),
https://www.imshealth.com/deployedfiles/imshealth/Global/North%20America/United%20States/Managed%20Markets/5-2914%20Specialty_ Drug_Trend_Whitepaper_Hi-Res.pdf.
9 The estimates in this section are based on published reports, some of which use different definitions for a specialty drug.
However, the various authors do note that drug price or cost is used as part of their respective definitions of specialty.
10 UnitedHealth Center for Health Reform and Modernization, The Growth of Specialty Pharmacy: Current Trends and Future
Opportunities (2014), http://www.unitedhealthgroup.com/~/media/UHG/PDF/2014/UNH-The-Growth-Of-Specialty-Pharmacy.ashx.
11 Ibid.
12 Express Scripts, “Super Spending: U.S. Trends in High-Cost Medication Use” (2015), http://lab.expressscripts.com/insights/drug-options/super-spending-us-trends-in-high-cost-medication-use.
13 Ibid.
14 Kaiser Family Foundation, Medicare Part D at Ten Years: The 2015 Marketplace and Key Trends, 2006-2015 (2015),
http://kff.org/medicare/report/medicare-part-d-at-ten-years-the-2015-marketplace-and-key-trends-2006.