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July DTR Analysis
July DTR Analysis
The specialty pharmaceutical category has left managed care executives scratching their heads over whether to keep it under the medical benefit or carve it out to the pharmacy benefit, according to industry experts.
“The medical plans know it is expensive, but strategies to address it are all over the board,” according to Tim Thomas, RPh, senior vice president, clinical services for HealthTrans. “There are many specialty providers that are talking and trying to influence the decision makers to carve out the specialty drugs to a specialty provider. This makes a lot of sense in some ways-better claims processing data, etc. However many physicians will resist this movement.”
Because plans do not know what to do with specialty drugs, fourth tier is rising in percentage use, according to Thomas.
The three-tiered benefit design has capped out, but this is not surprising, Thomas says. The three-tiered benefit has just about lived out its useful life,” he says. “A prescription benefit that educates the member about drug and therapeutic choices, will need to evolve. This is one of the main characteristics of consumer driven healthcare,” he says.
In 1991, Thomas designed a three-tiered benefit with a $5/$10/$15 copay. “The average cost of a brand prescription was close to $25. So the patient was paying about 50% to 55% of the cost of a third-tier drug. Now even with a $10/$25/$40 copay structure, a patient choosing a third tier drug like Nexium only pays about 25% to 30% of the total cost.”
It still surprises Thomas that the two-tiered benefit structure is used 64.5% of the time by health plans. “Executives will have to address this issue with their union plans as a two-tiered benefit with low copays is just not economically viable anymore,” he says.
A Conversation With Greg Baker, RPh, CEO of AffirmedRx
March 31st 2024Greg Baker, CEO of AffirmedRx, describes his early career, shares some of his critical opinions about the pharmacy benefit management (PBM) industry and how, in his view, his company is offering a better alternative.
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David Calabrese of OptumRx Talks New Role, Market Insulin Prices and Other Topics 'On His Mind'
April 13th 2023In this month’s episode of the "What's On Your Mind podcast," Peter Wehrwein, managing editor of MHE connects with the now Chief Clinical Officer of OptumRx Integrated Pharmacies, David Calabrese. In this conversation, David touches on his transition in January as OptumRx’s former chief pharmacy officer and market president of health plans and PBMs to his new role as Chief Clinical Officer where he now focuses more on things such as specialty pharmacy to home delivery — with an overall goal of creating whole-patient care. Throughout the conversation, Calabrese also touched on the market’s hot topic of insulin prices and behavioral health services within the OptumRx community, among other topics.
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Florida Gets the OK. But Will Drug Importation from Canada Actually Happen?
March 5th 2024Canadian health officials warn that maintaining a drug supply for Canadians is their priority. The staunch opposition of the U.S. pharmaceutical industry may also be an obstacle to imports from north of the border.
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Briana Contreras, editor of Managed Healthcare Executive, spoke with Nancy Lurker, CEO and president of EyePoint Pharmaceuticals. Nancy shared a bit about EyePoint and how the organization’s innovative therapies are addressing patient needs through eye care, and most importantly, she addressed C-Suite positions like the CEO role. Nancy shared advice for those seeking to reach the CEO level, especially toward women in healthcare and other roles, and what it takes to run a biopharma company.
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What Payers Need to Know As Retail Pharmacies Move Into Primary Care
September 6th 2023Healthcare beyond the doors of the doctor’s office has the potential to offer more care to more people. But payers need to think about how to ensure that care is consistent. Regardless of the setting, care decisions must be based on evidence-based content and supported with strong patient education.
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