Turn a pharmacy Score priority into a specialty-drug review action

A low pharmacy and specialty-drug management score is a signal to look beyond the pharmacy trend line. Specialty medications can be essential, life-changing therapies, but a small number of claims can also reshape the plan’s financial performance. Leadership needs a way to understand the clinical need, the contracting arrangement and the alternatives before costs become a year-end surprise.

The High Performance Health Plan treats pharmacy as a strategic purchasing and care-management decision—not a benefit that can be delegated without oversight. The work begins by SEEING the full picture: who receives specialty drugs, which conditions and products drive spend, what support is offered, how the benefit is sourced and what incentives may influence the recommendation.

For the next 90 days, establish a specialty-drug review for the plan’s highest-impact therapies. Request a clear baseline of specialty spend, top therapeutic categories, new starts, dispensing channels, prior-authorization outcomes, manufacturer assistance activity and all pharmacy-benefit-manager or specialty-pharmacy compensation. Put the information into one decision-ready view, using consistent definitions and time periods.

At the review, ask four management questions: Is the therapy clinically appropriate? Is the member receiving support to start and stay on the right treatment? Is the chosen channel producing the best available value? And can the vendor explain every fee, rebate and financial incentive connected to the claim? Assign an owner, document unanswered questions and set a deadline for resolution.

This Roadmap action does not ask an employer to solve pharmacy in one quarter. It establishes the governance habit that makes smarter decisions possible: a recurring review of high-impact therapies, transparent sourcing and accountable follow-through. From that baseline, leaders can improve benefit design, site-of-care coordination and vendor contracts while protecting access to clinically appropriate care.