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Coverage for specific drug classes


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.


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 WalkerCommentary is independent of source data

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