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PubMedDate not supplied

Insurers' strategies for managing the use and cost of biopharmaceuticals.

This paper examines strategies under development by health insurers to manage biopharmaceuticals, as their use spreads beyond rare diseases and academic sub-specialists to common conditions and community-based practices. Emphasis is placed on medical management (formulary placement and prior authorization), network design (physician contracting and drug distribution), and benefit design (coinsurance and annual payment limits). Contemporary initiatives are modest in ambition but potentially lay the foundation for a framework that balances access to innovation with affordability in this dynamic industry.

Biopharmaceutics↗
PubMedDate not supplied

Access to cancer drugs in Medicare Part D: formulary placement and beneficiary cost sharing in 2006.

The Medicare Part D benefit expands the universe of cancer drugs and biologics that Medicare may cover. Individual Part D plans have discretion to determine their formularies and cost sharing for drugs within federal guidelines. This paper analyzes differences in coverage and cost sharing for cancer drugs among these plans. We find that many cancer drugs, including brand-name products, are covered by almost all plans, although prior authorization might limit access to some. In addition, many plans charge a relatively low copayment for most cancer drugs. These findings suggest that Part D could greatly expand beneficiaries' access to cancer treatments.

Biological Products↗
PubMedDate not supplied

Health plans' strategies for managing outpatient specialty pharmaceuticals.

Balancing increased spending for specialty pharmaceuticals while providing affordable and equitable coverage for consumers is a key issue for public and private payers. Health plans rely on an array of strategies, including both medical management and those used for more traditional pharmaceuticals. To explore specific management strategies for outpatient specialty pharmaceuticals, a survey was administered to thirty-eight Blue Cross and Blue Shield plans, focused on identifying core strategies. Prior authorization was the most commonly used strategy, implemented by 83.3 percent of respondents. Other frequently implemented management strategies included claims review (82.8 percent), formulary management (76.7 percent), and utilization review (70 percent).

Ambulatory Care↗
PubMedDate not supplied

Managing biotechnology in a network-model health plan: a U.S. private payer perspective.

Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology.

Biological Products↗
PubMed2006

A first look at the new Medicare prescription drug plans.

Medicare began offering an outpatient prescription drug benefit through private plans in January 2006. Using nationwide data, we examine the availability, costs, and benefits of regional and local plans offering these benefits to beneficiaries. Because they are an entirely new concept for Medicare, we focus on stand-alone prescription drug plans, comparing them with other Medicare health plans offering drug coverage. The infamous "doughnut hole" exists for all but a few of these plans. One national stand-alone drug plan, though, covers brand-name drugs with no gap. Variations in cost sharing and formularies provide beneficiaries with choices as well as complexity.

Cost Savings↗
PubMed2006

Emerging lessons from the drug effectiveness review project.

The Drug Effectiveness Review Project (DERP) is an alliance of fifteen states and two private organizations, which have pooled resources to synthesize and judge clinical evidence for drug-class reviews. The experience shines a bright light on challenges involved in implementing an evidence-based medicine process to inform drug formulary decisions: When should evidence reviewers accept surrogate markers and assume therapeutic class effects? How open and participatory should review procedures be? Should reviewers consider cost-effectiveness information? What is the appropriate role of the public sector in judging evidence? The DERP illustrates that attempts to undertake evidence-based reviews, apart from the methods themselves, which continue to evolve, involve questions of organization, process, and leadership.

Cost-Benefit Analysis↗
PubMed2006

The drug effectiveness review project: an important step forward.

Peter Neumann's paper on the Drug Effectiveness Review Project (DERP) is a constructive if incomplete point of departure for discussing the work done by the project and the use of that work by decision-makers in states and elsewhere. This Perspective attempts to establish the proper context for judging the DERP by comparing its product and processes with those commonly produced and used by industry and other parties. It also provides a direct response to the criticisms of the project noted by Neumann.

Cost-Benefit Analysis↗
PubMed2006

The DERP: is it an effective methodology?

The Drug Effectiveness Review Project (DERP) is a process with challenges as well as rewards. This Perspective explores the issues that hamper the DERP's effectiveness and discusses the changes it has generated in the drug review process for pharmacy and therapeutics (P&T) committees. The need for more timely and substantial evidence is a key barrier to all drug review processes; here I offer some alternative methods for comparing new drugs that have few comparators. A perfect process is a long way off. However, continuing to explore the methodologies in place today can lead us to more effective processes and metrics.

Cost-Benefit Analysis↗
PubMed2006

Evidence-based coverage decisions? Primum non nocere.

Drug class reviews are blunt tools for medical decision making. The practice of evidence-based medicine is far more than simply systematic reviews: The patient and doctor are integral. Here we highlight areas of evidence-based coverage decision making where greater balance and transparency could serve to improve the current process, and we recommend elements of a more positive approach that could optimize patient outcomes under resource constraints.

Cost-Benefit Analysis↗
PubMed2006

Bringing the DERP to consumers: 'Consumer Reports Best Buy Drugs'.

Consumers Union, publisher of Consumer Reports magazine, has used the drug class reviews of the Drug Effectiveness Review Project (DERP) as one critical component of a free public information project on the comparative effectiveness, safety, and cost of prescription drugs. The project translates the DERP findings for consumers. Drawing on other sources and adding information on drug costs, the project chooses Best Buy drugs in each category it evaluates. This guidance can help consumers save up to thousands of dollars per year, and it has the potential to reduce overall drug spending.

Consumer Organizations↗
PubMed2003

Designing pediatric vaccine formularies and pricing pediatric combination vaccines using operations research models and algorithms.

The National Immunization Program, housed within the Centers for Disease Control and Prevention in the USA, has identified several challenges that must be faced in childhood immunization programs to deliver and procure vaccines that immunize children from the plethora of childhood diseases. The biomedical issues cited include how drug manufacturers can combine and formulate vaccines, how such vaccines are scheduled and administered and how economically sound vaccine procurement can be achieved. This review discusses how operations research models can be used to address the economics of pediatric vaccine formulary design and pricing, as well as how such models can be used to address a new set of pediatric formulary problems that will surface with the introduction of pediatric combination vaccines into the US pediatric immunization market.

Algorithms↗
PubMed2004

The effect of deinsuring chlorpropamide on the prescribing of oral antihyperglycemics for Nova Scotia Seniors' Pharmacare beneficiaries.

On behalf of the Nova Scotia Seniors' Pharmacare Program, the Drug Evaluation Alliance of Nova Scotia developed a multicomponent intervention plan to facilitate the removal of chlorpropamide as an insured benefit. Chlorpropamide has caused serious hypoglycemia in seniors to a greater extent than some other agents. Pharmacy administrative claims were used to compute monthly use rates for insulin and each oral antihyperglycemic drug from January 1, 2000-December 30, 2002, in an intervention cohort (patients receiving chlorpropamide) and a control cohort (patients receiving an antihyperglycemic agent other than chlorpropamide). Initially, 630 patients were receiving chlorpropamide therapy. By the time chlorpropamide was deinsured, only 10% of the treatment cohort continued receiving chlorpropamide; shortly after deinsurance, no beneficiaries continued receiving the drug. The antihyperglycemics with the greatest increase in prescription were glyburide and gliclazide. The deinsuring of chlorpropamide and the educational strategies that accompanied it resulted in the selection of more appropriate antihyperglycemics for Nova Scotia seniors.

Aged↗
PubMed2006

Nurse prescribing.

Explore the source record for details and available documents.

Drug Prescriptions↗
PubMedDate not supplied

Effects of a 3-tier pharmacy benefit design on the prescription purchasing behavior of individuals with chronic disease.

OBJECTIVE: To evaluate the impact of 3-tier (copayment) pharmacy benefit structures on medication utilization behavior. METHODS: A pretest-posttest quasi-experimental design was employed. Chronic disease sufferers (N=8,132) from a health plan were classified into the following groups: (a) 2-tier copayment moving to a 3-tier structure, (.converting. group), (b) 2-tier staying in a 2-tier structure and, (c) 3-tier staying in a 3-tier structure. The latter 2 were.comparison. groups. Two 7-month time periods were determined: the.preperiod. (June through December 2000) and the.postperiod. (January through July 2001) for a change in pharmacy benefit structure. Pharmacy claims data were used for data collection. Statistical analyses included bivariate tests to evaluate predifferences and postdifferences across study groups. Maximum likelihood estimates from a repeated measures model were used to examine changes in formulary compliance and generic use rates. Discontinuation of nonformulary medications was evaluated using logistic regression. RESULTS: Controlling for demographics, number of comorbidities, disease state, and pharmacy benefit structure, the formulary compliance rate increased by 5.6% for the converting group. No significant increases were seen for the comparison groups. Generic use rates increased by 6 to 8 absolute percentage points for all groups (3.3% to 4.9 % adjusted rates). Converting group members were 1.76 times more likely to discontinue their nonformulary medication than those in the 2-tier comparison group and 1.49 times more likely than those in the 3-tier comparison group. CONCLUSIONS: These findings suggest that shifting individuals from a 2-tier to a 3-tier drug benefit copayment structure resulted in changes in medication utilization. Decision makers need to balance these changes with the potential dissatisfaction that members may express in paying higher copayments.

Aged↗