Health plans are drawing on existing benefits language to make coverage decisions about mifepristone, the newly approved abortion pill. The pill is administered directly by prescribers, so it is not treated as a pharmacy benefit. Among others, PacifiCare, Aetna U.S. Healthcare, Cigna, and United HealthCare cover mifepristone (also known as RU-486) as a standard medical benefit — the same as surgical abortion. Where family planning services are a covered benefit, mifepristone will be covered as an in-office procedure under that category, a pharmacy benefit. PacifiCare, Aetna U.S. Healthcare, Cigna, and United Healthcare, among others, cover mifepristone (also known as RU-486) as a standard medical benefit — as with surgical abortion. Where family planning services are covered, mifepristone will be considered an in-office procedure.

While projections show medical abortions may replace more than 30 percent of surgical abortions, the financial impact on health plans is expected to be negligible, because mifepristone's cost is comparable to that of surgical abortion.

Sam Ho, M.D., vice president and corporate medical director for PacifiCare, says its coverage decision was based on an evaluation of scientific literature, followed by a determination of which of its plans cover abortion. Because there is flexibility in the administration of mifepristone, PacifiCare developed clinical guidelines for use and dosage.

The difference between mifepristone and some other drugs, in terms of coverage decisions, involves splitting medical necessity from covered benefits. "Treatment of male impotence is a covered benefit, but much use of Viagra isn't truly medically necessary," Ho says by way of example. "So to provide Viagra when appropriate, we have guidelines for its use."

The Department of Health and Human Services is still determining whether Medicaid programs should cover mifepristone — and the implications may be huge, according to Daniel C. Malone, Ph.D., R.Ph., assistant professor at the University of Arizona College of Pharmacy. "This will be a sensitive subject for many states. It may reverse their portfolio of covered products in terms of reproductive medications."

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.