Despite the recent news that Medicare will not exclude erectile dysfunction drugs from coverage limitations, health plans responded with a ho and a hum. That's because when sildenafil (Viagra) arrived on the scene in 1998, health plans and employer groups got together and hashed out a benefit package that took into account the risks, benefits, and cost.

David Clark, RPh, MBA, vice president for pharmacy benefit management at the Regence Group, says, "It's not something we're looking at to include in our commercial benefits. I think that those plans that cover it today will continue providing coverage. But those that have set it up as an exclusion, as in our situation — I don't see a need for a change."

Will this open the door for other so-called lifestyle drugs to gain coverage? "Probably not for this therapeutic category, but for other lifestyle drugs that are not so 'lifestyle oriented.' For example, weight control drugs that may receive an indication for diabetes will have a bigger effect on formulary structure," says Clark.

Historical data from MediMedia's Formulary Compass, a continuously updated compilation of formulary information, shows sildenafil with the most coverage by health plans (without prior authorization) as well as tier 2 position in more than 24 percent of plans surveyed in 2005.

Erectile drug coverage and formulary position

Source: MediMedia's Formulary Compass

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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.