More on drug classes from the March 2006 Desktop Resource

March 1, 2006

The challenges of medical versus pharmacy benefits faced by payers are unique and vary by category, say industry watchers (See Desktop Resource, March 2006). Some of the following drug classes can fall under both benefit arrangements.

The challenges of medical versus pharmacy benefits faced by payers are unique and vary by category, say industry watchers (See Desktop Resource, March 2006). Some of the following drug classes can fall under both benefit arrangements.

"If a large technology employer with a relatively young demographic has employees who have waited to become pregnant until their mid- to late-30s, or more, and are having difficulty, then the employer might feel compelled to have the health plan offer fertility benefits to satisfy its employees, as well as to stay competitive for attracting and retaining these employees," he says.

"One need only watch commercials during professional sporting events to see the marketing of sexual dysfunction pharmaceuticals to men and women watching," he says. "They initially were targeted at dysfunction, but have not progressed to include dysfunction and performance, and are targeted at men and women. While this may not be a prime example, if employees of large employers want a service, and if demand for those employees is competitive, despite potential rising costs, health plans will offer them as benefits."

Finally, Mack says that shifting more cost-sharing to physicians could, at some point, cause them to drop out from certain health plans or stop offering the benefit altogether.

"This has long been a battleground in negotiations between health plans and providers: what is paid for by the health plan, and what is the responsibility of the providers," he says.