Managed care coverage for specific drug classes

March 1, 2006

Savvy executives note challenges in pharmacy versus medical benefits, say industry experts.

"Most drugs have some area of challenge, but they are all different," says Alan T. Wright, MD, MPH, vice president, product strategy, Resolution Health Inc.

According to Joseph M. Mack, MPA, senior vice president Beecher Carlson Healthcare Practice, Irvine, Calif., aside from certain diseases that are prevalent, more uncertainty is in coverage for sexual dysfunction, smoking prevention and anorexiant drugs. "For sexual dysfunction and smoking cessation drugs, a majority of plans offer these drugs as a pharmaceutical benefit, but many still do not provide coverage. Anorexiant drugs are offered by many plans as a benefit, but most do not cover them. Fertility drugs are split approximately evenly between those plans that offer them as a benefit, and those that do not," he says.

If a large employer has competition from other employers for the same employees, then the employer might want to offer additional benefits to attract and retain those targeted employees.

"The bottom line is . . . health plans must offer benefits that employers demand and which are not always economically or clinically 'proven,'" Mack says.

The therapeutic categories shown are standard carve-out classes on most plans' radar screens because of the high cost and utilization management tools needed to ensure appropriate use, says Robert Kordella, RPh, chief clinical officer at National Medical Health Card Systems (NMHC), a PBM. "Most plans are evaluating high-cost drivers such as the injectables and biotech drugs in which specialty pharmacy could be beneficial in managing both the cost and clinical outcome for the patient," Kordella says.