- Hypertrophic Cardiomyopathy (HCM)
- Vaccines: 2023 Year in Review
- Eyecare
- Urothelial Carcinoma
- Women's Health
- Hemophilia
- Heart Failure
- Vaccines
- Neonatal Care
- NSCLC
- Type II Inflammation
- Substance Use Disorder
- Gene Therapy
- Lung Cancer
- Spinal Muscular Atrophy
- HIV
- Post-Acute Care
- Liver Disease
- Pulmonary Arterial Hypertension
- Biologics
- Asthma
- Atrial Fibrillation
- Type I Diabetes
- RSV
- COVID-19
- Cardiovascular Diseases
- Breast Cancer
- Prescription Digital Therapeutics
- Reproductive Health
- The Improving Patient Access Podcast
- Blood Cancer
- Ulcerative Colitis
- Respiratory Conditions
- Multiple Sclerosis
- Digital Health
- Population Health
- Sleep Disorders
- Biosimilars
- Plaque Psoriasis
- Leukemia and Lymphoma
- Oncology
- Pediatrics
- Urology
- Obstetrics-Gynecology & Women's Health
- Opioids
- Solid Tumors
- Autoimmune Diseases
- Dermatology
- Diabetes
- Mental Health
June DTR Analysis: Uncovering administrative barriers
June DTR Analysis: Uncovering administrative barriers
An opportunity exists for managed healthcare executives to help physicians go beyond the typical barriers to accessing certain medications, according to Richard G. Stefanacci, DO, founding executive director of the Health Policy Institute at the University of the Sciences in Philadelphia.
“These are most often barriers in the form of an administrative requirement. But plans also use financial benefits, usually on patients again to limit access,” Dr. Stefanacci says.
“First, an opportunity to move from a barrier system to one that-through an active medication therapy management system-assists prescribers in getting the right medication to the right patient. This would result in higher percentage of plans focusing on reducing adverse side effects through appropriate prescribing.”
Second, he says, there’s an opportunity to move from fax and phone to a point-of-care system as e-prescribing becomes more common. “Currently it’s done through a fax sheet that requires the physician or their staff to answer clinical questions,” Dr. Stefanacci says.
Finally, given that the Medicare Prescription Drug Benefit allows plans to exclude from coverage certain medications as well as off-label use, there will be an opportunity to use prior authorization to assure that these non-covered medications are not paid for, according to Dr. Stefanacci.
“For example, Megace [megestrol acetate] is covered when used for cancer,” he says.
“Plans use prior authorization to assure it's not used for weight gain, which is excluded for Part D coverage. Neurontin [gabapentin], which is used off-label will be subject to prior authorization so they can limit their coverage to labeled-use only.”
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.
Read More
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.
Listen
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.
Read More
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.
Listen
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.
Read More
