In my conversations, I’ve discovered that many people don’t fully appreciate the role of the government as a payer.
As I show below for 10 specialty drugs, Part D and Medicaid are very important payers for specialty drugs covered under a pharmacy benefit. The influence of Part D will grow because the PPACA-mandated closing of the coverage gap (donut hole) will take full effect in 2020 and give patients better coverage for specialty drugs.
Why does this matter?
- Entrepreneurial independent pharmacy owners are acquiring patients who take specialty drugs and rely on Medicare Part D or Medicaid coverage. Any Willing Provider laws require that these pharmacies be permitted into the specialty network of a Part D provider.
- Manufacturers that lack a well-designed channel strategy and use sloppy class-of-trade guidelines will discover that their specialty products are being dispensed from a much broader set of pharmacies than they expected.