The fact that these drugs represent less than 1 percent of all medications used by injured workers is by no means a reason to overlook them. Because of the high costs associated with specialty medications, payers need to stay vigilant in understanding and addressing this small but growing segment of pharmacy spend.
The Issue
HIV, osteoarthritis, high cholesterol, and hepatitis C are among the comorbidities that require prescriptions for specialty medications. Just over 2 percent of injured workers used one of these drugs last year, accounting for 0.6 percent of all prescriptions filled and 6.3 percent of total pharmacy spend.
The most used specialty drug for injured workers in 2017 based on per-user-per-year spend according to myMatrixx, was Truvada®, used to treat pre-exposure to HIV. The cost per Rx was $1,019.11. The overall use of medications to treat HIV increased by 17.6 percent — not too surprising considering the need for them to treat workers with occupational exposure to needle sticks.
However, the use of medications to treat osteoarthritis rose 21.6 percent, while the cost per prescription increased 1.1 percent. The medication Synvisc had increased utilization of more than 58 percent. Driving the increase was likely the fact that workers may use the drug for repetitive stress injuries caused by activities that stress the knee joint — squatting, kneeling or lifting heavy objects.
The most expensive medication on the top 10 list is Epclusa®, with a price tag per Rx of $24,510. However, the drug has been hailed as curing the disease.
Affected Workers
Workers in a variety of occupations may need specialty drugs.
- Medical workers may contract HIV and hepatitis C from blood-borne pathogens due to exposures to needlesticks.
- Coal miners are at risk of black lung disease
- Outdoor workers are vulnerable to Lyme disease.
Other reasons workers may need specialty drugs include postoperative blood clots and organ failure.
The Drugs
The top 10 specialty medications for 2017 according to myMatrixx were:
Drug Therapy Class
Truvada® HIV
Isentress® HIV
Synvisc-One® Osteoarthritis
Xolair® Asthma
Enbrel SureClick® Inflammatory conditions
Enoxaparin Anticoagulant
Repatha SureClick® High cholesterol
Enbrel ® Inflammatory conditions
Xyrem® Anti-cataplectic agents
Epclusa® Hepatitis C
What to Do
It’s important for claims handlers and injured workers to have a clear understanding of how and why they are using these medications. They often require special handling instructions, for example. While denying a specialty medication to an injured worker in need would not be prudent, organizations can rein in costs and prevent overutilization by ensuring the drugs are used appropriately and judiciously.
- Train. Injured workers and those involved with the claim should know what side effects may be present with each specialty medication. Injured workers should be well informed about self-administering the medications.
- Monitor. These injured workers often need ongoing clinical monitoring and more intensive help from pharmacists and other caregivers to ensure they are taking the medications as prescribed, as patient adherence is crucial.
- Use specialists. Specialty pharmacies are better equipped and should be utilized for handling these medications, as they typically offer services not available at retail pharmacies. For example, on-staff nurses and physicians who are experts in the conditions and treatment are likely to be available only in specialty pharmacies.
- Engage physicians. Nurse case managers and other caregivers should work with treating physicians to make sure the injured worker is getting the proper medications and treatment. Some medications, including Repatha for high cholesterol, are appropriate only for a small number of patients and must be appropriately managed for patient safety and costs. Cancer medications are not usually included in workers’ compensation formularies and therefore may require prior authorization.
Conclusion
Specialty medications represent just a fractional component of prescriptions filled by injured workers, yet their costs can be nearly prohibitive. Since they offer an important lifeline for injured workers who truly need them, it’s important to see they are prescribed only where appropriate and are taken as prescribed.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.
