Specialty drugs are high-cost medications for chronic, complex, or rare conditions (like cancer, MS, or genetic disorders). Their costs are driven by advanced manufacturing, limited patient populations, and tight patent protections, making generic competition rare.

Though they may only affect 1–2% of employees, specialty drugs often account for 50–80% of pharmacy spend—making them a major driver of cost volatility. Managing them well is one of the few lever points where self-funded employers can materially reduce overall health plan spend.

Spread pricing is when a PBM charges the employer more than what it pays the pharmacy, pocketing the difference. This opaque markup inflates costs and prevents employers from seeing the true price of medications.

With a transparent or pass-through model, all discounts, rebates, and savings flow back to the plan, and pricing is disclosed. This structure aligns the PBM’s incentives with yours and gives you full visibility into what you’re paying.

Overlay programs sit on top of your PBM and source specialty medications from alternative—often lower cost—channels. These programs can reduce costs by 30–60% while keeping the drug therapy unchanged.

Biosimilars are clinically equivalent versions of biologic drugs but typically cost 30–50% less. When included in formulary design and promoted appropriately, biosimilars can deliver significant savings without compromising outcomes.

These programs allow drugmakers (or foundations) to cover patient costs, shifting burden away from both the plan and employee. When integrated properly, they can yield savings in the tens of thousands for eligible members.

Yes—with proper oversight. For certain therapies, vetted specialty or international pharmacies can deliver identical medications at lower cost while complying with FDA import regulations. Quality, safety protocols, and regulatory compliance are essential.

GLP-1s (like Ozempic, Wegovy, Mounjaro) carry high monthly costs—often $1,000+. Employers should establish clear clinical criteria, eligibility protocols, and tie usage to wellness or behavioral programs to drive value rather than open-ended coverage.

Use predictive analytics to flag emerging high-cost treatments, apply clinical review protocols early, and work with specialty pharmacies or manufacturers on outcome-based contracts. That way, you can contain cost spikes before they hit your bottom line.

Real-time tools like Roundstone Reporting allow employers to identify trending therapeutic classes, outlier claims, and utilization shifts before they escalate. That visibility enables preemptive interventions instead of reactive fixes.

While rare-disease or orphan drug therapies can be expensive, providing robust support programs—case management, financial aid navigation, and linkage to foundations—can improve adherence, reduce complications, and ultimately protect your plan from higher downstream medical costs.

In a captive model, employers retain control and benefit directly from cost savings. Transparent contracts, shared risk, and alignment of incentives ensure that savings from specialty drug strategies return to the plan rather than to intermediaries.

Yes, for many captive members, especially in their first few years of transitioning to more transparent models and overlay strategies. Over time, consistently applying advanced containment tactics can deliver significant and sustainable savings.