The Promise and Pitfalls of Specialty Pharmacy Carveouts, and Why the Right Partner Matters
Specialty medications represent one of the fastest-growing and most expensive areas of healthcare. For many health plans and employers, these drugs account for a disproportionate share of total pharmacy spend, often exceeding 50% of overall drug costs despite serving a small percentage of members.
That’s where carveouts come in. They help manage specialty pharmacy spend while keeping care accessible.
Enter the Specialty Pharmacy Carveout
A carveout removes specialty drug coverage from the medical or pharmacy benefits and manages it through a separate, specialized program. The goal is simple: gain better cost control, access to manufacturer rebates, and more tailored patient support. But like most things in healthcare, the reality is more complex.
Why Carveouts Work
When done well, carveouts can deliver significant benefits:
- Cost savings through improved purchasing power, better contract terms, and access to manufacturer assistance programs.
- Expert oversight from specialists who understand complex drug handling, dosing, and side-effect management.
- Better member experience with personalized support, adherence coaching, and streamlined refills.
For payers and employers, this often translates into reduced financial risk and improved member outcomes, a rare win-win in healthcare.
The Drawbacks No One Talks About
Carveouts are not a silver bullet. Poorly executed programs can lead to:
- Fragmented care, with a disconnect between prescribers, pharmacies, and case managers.
- Access barriers, where members face delays in receiving critical medications due to rigid protocols.
- Administrative complexity that eats into the savings if the program isn’t well integrated with other benefits.
In some cases, the wrong carveout partner can increase costs or member frustration, eroding trust in the benefits program.
Why the Right Specialty Pharmacy Carveout Partner Makes All the Difference
The key to a successful specialty pharmacy carveout isn’t just the model; it’s the execution. The right partner coordinates care seamlessly, balances cost savings with member access and satisfaction, and adapts quickly to market changes, new therapies, and evolving regulations to keep your strategy ahead of the curve.
Specialty drug costs aren’t slowing down, and neither should your approach. As carveouts become more common, choosing a partner with deep expertise, proven systems, and a member-first philosophy will determine whether your program delivers on its promise.
Final Thoughts
Specialty pharmacy carveouts can be a powerful tool for managing costs and improving care. But like any tool, their effectiveness depends on how and by whom they are used.
At Golden Triangle Specialty Network (GTSN), we’ve been watching this space closely and are excited about where it’s headed. The future of specialty drug management isn’t just about cutting costs; it’s about building smarter, more connected systems that work for everyone involved.
If you’re ready to explore how the right carveout strategy could work for your organization, our team at GTSN is here to help you make it happen.