OVER THE NEXT few years, more health plans and employers will investigate covering the physician-administered injectable drugs
under the pharmacy benefit as a way to control the costs and manage appropriate utilization, says Kathryn Lindhorst Canaday,
PharmD, director of pharmacy analysis, Pharmaceutical Strategies Group (PSG), based in Dallas.
"Employers will begin to ask their health plans to demonstrate that the pricing for the drugs under the medical benefit is
equivalent to the pricing they can receive under the pharmacy benefit through their PBM. If it is not equivalent, then the
employers will require the injectable drugs to come under their pharmacy program," Dr. Canaday says.
According to her, implementing prior authorization, step therapy or quantity limits are done more easily in the pharmacy system
than in the medical system.
Each MCO has unique situations that must be considered when making coverage determinations, such as benefit design, member
demographics variances, and more, says Ryan Haynes, RPh, director of clinical services at HealthTrans, Greenwood Village,
Colo. "Many of the defined categories illustrate why specialty pharmacies exist and are such an important component of the
overall drug benefit coverage, as well as a tool for managing escalating costs," he says. EXCEPTION TO THE GENERAL RULE
There is however, an exception, namely, mixing the medical and pharmacy benefits. Dr. Canaday observes that the member copayment
or coinsurance is the biggest difference between pharmacy and medical benefit. "In the past, there hasn't been any copayment
or coinsurance on drugs administered in a physician's office," she says. "But this is changing as payers face increased costs
from specialty drugs."
Blending of medical and pharmacy data, says Haynes, has allowed better outcomes measures by looking at the total healthcare
spend. "However, carving out the pharmacy benefit, too, has its advantages, such as allowing for tighter drug therapy controls,"
he says. Tighter control can mean more in-depth knowledge of specific data elements such as drug, dose, strength, day supply,
etc., that is captured when the drugs are processed through the pharmacy benefit administrator.
Another advantage of processing these medications through the pharmacy benefit is that the systems are in place to capture
and identify potential drug-drug interactions and drug-disease contraindications. "The data and reporting capabilities are
also an advantage of the pharmacy benefit when compared with the medical benefit," Haynes says. "One can track and trend the
drug spend more accurately and in a more timely fashion."
But, drug spend should not be the sole focus. "Managing overall healthcare spend is the ultimate goal for any MCO," Haynes
says. "Without improved patient outcomes as a result of effective drug therapy, significant medical and pharmacy resources
are at risk, not only in cost but ultimately in patient care. There is no one single solution . . . Organizationally-specific
variables ultimately must drive decision-making processes."
—Tracey Walker
Commentary is independent of source data
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