What Makes A Drug Special?: Understanding PBMs’ Pharmacy Definitions

Health Affairs January 7, 2025
Dylan Kacerek, T. Joseph Mattingly II

Prescription spending has increased substantially in recent years, growing to more than $630 billion in the US in 2022. Of that, approximately 51 percent of total pharmaceutical spending was on specialty drug products, increasing at a faster rate than non-specialty drug spending. In 2021, Delaware’s Department of Insurance found that 44 percent of total drug spending for fully insured commercial plans in Delaware came from 1 percent of the total pharmacy claims in their analysis.

The growing disproportionate amount of drug spending on such a small subset of pharmaceuticals has led many policy makers to focus on these specialty drug products. But this policy focus raises several fundamental questions such as: How is a specialty drug defined; who creates the...

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