December 10, 2020

Drug exclusions



More and more self-funded employer group health plans are making some tough choices for 2021 and beyond with their plan benefits. One of them happens to be with specialty drugs – and subclasses of these specialty drugs, such as orphan drugs and gene therapies.

Tough Choices

  • Some self-funded employers have elected to cover only generic drugs moving forward and exclude specialty drugs and brand name drugs altogether.
  • Others elect to exclude only gene therapies.
  • While others exclude orphan drugs and gene therapies.

Considering that specialty drugs are costing self-funded plans anywhere from 30-85% of the total prescription spend and the increasing numbers of gene therapies, orphan drugs, and specialty drugs at high numbers in the drug pipeline, the tough choices will only continue.

If a self-funded plan elects some or all of these prescription benefit exclusions, what then or how can the patient still get affordable access to these therapies? Believe it or not, there are several options for the patients – which we recommend HR pros share with their employees:

How to Get Help on Excluded High Dollar Specialty Brand Drugs

  1. First, the patient could go direct to the drug manufacturer and see what patient assistance programs are offered, if any. If the patient isn’t sure who manufactures the drug, a quick check of the drug at DailyMed ( by inserting the brand name of the drug will pop up the drug package insert, and at the very top or bottom of that drug package insert should list the manufacturer. Or, if the drug label and packaging is available, look at it to see who manufactures it.
  • Once the manufacturer has been identified, find the drug site and/or the drug manufacturer site and type in “patient assistance program” and see if anything comes up.
  • The patient may have to fill out an extensive form to attempt to get the drug for free or a significant discount.
  1. The patient can also try NeedyMeds ( by typing in the drug name to see what discounts, copay coupons and/or patient assistance programs come up for your drug as well.
  2. Confusing? Then the patient may hire someone to help – There are several pharmacy advocacy vendors who will allow patients to hire them direct when drugs aren’t covered under a plan. They range in price from $39-60 per month and often provide free assessments in advance to see if they can even assist before they are hired. Your broker should know which organizations serve patients directly, and how they work. If they don’t, talk to us – we do, and we can help.

Erin L. Albert

Authored By

Erin L. Albert, MBA, PharmD, JD, PAHM

Pharmacy Benefit Practice Leader
Meet Erin L.