High-Cost Specialty Drugs
QALYiQ™ Contains Costs snd Supports Access to Rare or Orphan Drugs
Rare diseases, also known as orphan diseases, are conditions that affect fewer than 200,000 people in the United States.1 Although they impact a small portion of a population, drug manufacturers are investing in new therapies that have the potential to make a difference in patients’ lives.
QALYiQ gives plan sponsors peace of mind
Most plan sponsors aren’t prepared for the financial impact of an orphan disease diagnosis. Just one prescription for an orphan drug can dramatically increase annual drug spend.
In 2023, more than half of newly approved drugs were for the prevention, diagnosis or treatment of orphan diseases.2 While these drugs advance care, they can be very expensive, with a median cost of over $200,000 annually.3
With QALYiQ, plan sponsors can feel confident that if a member needs a high-cost medication, they have safeguards in place to offset the unexpected costs.
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QALYiQ™ Overview
A framework to align high-cost medications with their value
What is a Quality-Adjusted Life Year (QALY)?
- Measures the value and benefit of health outcomes for a medication
- Helps to answer the question of whether the cost of a drug is in line with its clinical value
- Guides benefit design (e.g., drug tiers) through health economic review
What is QALYiQ?
- Identifies cost-saving opportunities when a drug’s price doesn’t match its clinical value.
- Connects members with manufacturer patient assistance and grant programs
- Reduces member and client costs for select specialty medications
The QALYiQ framework compares a drug’s cost to the years and quality of life it adds, helping manage both financial impact and treatment risk.
High-Touch Approach
How It Works
QALYiQ identifies certain drugs that, while clinically effective, are priced out of alignment with their clinical value. This helps to guide benefit designs.
For orphan and high-cost specialty drugs that fall under QALYiQ, members are connected with our access team, which investigates and connects them with manufacturer-provided patient assistance and grant programs to help reduce their costs.
If a member’s prescriptions are identified as candidates for QALYiQ, that member is put in touch with our access team. A member of our access team works with that member to obtain financial assistance from the manufacturer. With the prescription filled and costs adjusted for the individual member, the total plan specialty spend is reduced.