For many drugs, the biggest factor in the price isn't the drug at all. It's where and how it's sourced. The same infusion can cost several times more in a hospital outpatient department than in a doctor's office or at home, and the same specialty drug can carry very different costs depending on the pathway it's bought through.
Site of care is one driver, but it's not the whole story. A large share of spend now comes from high-cost specialty drugs sourced underneath the pharmacy benefit manager, where the price the plan pays is rarely the only option available. The cost depends on where the drug is administered (and the facility fee attached to that place), the spread between what a middleman pays and what it bills the plan, and which sourcing pathway is used. None of this is visible on a typical pharmacy benefit, which is exactly why it persists.
For those specialty drugs, savings are often available through alternative pathways that a coordinated program can pursue: variable coupon programs that offset member cost, international sourcing for select medications, and 340B pricing where a member and provider qualify. Alongside manufacturer assistance programs, and site-of-care guidance, these give the plan more than one way to pay for the same medicine, instead of defaulting to the highest-cost route.
One specialty infusion, identical dose. The only thing that changes is the setting it's given in, and the facility fee that rides along with it.
Prices are illustrative and chosen to show the site-of-care pattern that's well documented for provider-administered drugs. The right setting is always a clinical decision first, but when several are appropriate, the cost difference is large.
A facility fee can dwarf the drug itself. The same molecule costs far more in a hospital outpatient setting than in an office or at home.
A middleman can pay one price and bill the plan a higher one, keeping the difference. If it's invisible, it's hard to question.
High-cost specialty drugs need careful sourcing and management. Without it, the plan pays list-style prices by default.
The pharmacy function in the PR Health stack is built to surface these drivers instead of burying them, so the plan pays for the medicine, not the markup around it.
When more than one setting is clinically appropriate, navigation helps members choose a lower-cost one.
Pharmacy pricing is structured to reduce hidden spread, so the plan can see what it's paying for.
High-cost specialty drugs are sourced and managed deliberately, not paid at default list-style prices.
How the curated stack is coordinated as one accountable program.
