Retail pharmacies are less likely to dispense specialty drugs than in the past, according to the Pharmacy Benefit Management Institute’s 2009–2010 Prescription Drug Benefit Cost and Plan Design Report. In 2007, nearly 37 percent of employers surveyed said their plan benefit design allowed retail pharmacy to dispense specialty drugs, but that dropped to 28 percent in 2009. The report points out that not all retail pharmacies are equipped to handle refrigeration, compounding, and patient counseling that often go with specialty products. Depending on how the benefit design is structured, the pharmacy benefit can be delivered as part of the medical benefit (carved in) or it can be designed and managed separately from the medical benefit (carved out). The report says that 70.9 percent of carve-out employers offer a specialty pharmacy benefit, compared to only 41.6 percent of carve-in employers. Carve-out employers, which usually have 1,000 or more employees, are more likely to use their PBM as an exclusive supplier of specialty drugs. These employers are more likely to use pharmacy benefit managers and specialty pharmacies to manage the cost and utilization of specialty drugs. The 2009 survey was completed by 417 U.S. employers representing more than 7 million members.

  • My PBM is the exclusive supplier of specialty drugs
  • Our plan has established quantity limits for specialty drugs
  • Our plan requires all specialty drugs filed through our PBM contract to be dispensed from the PBM’s designated specialty pharmacy
  • We have restricted coverage in our medical plan to channel specialty drugs to PBM
  • Our plan permits dispensing of specialty drugs at retail pharmacies

*Respondents in 2008 were made up of slightly larger employer groups, compared to respondents in 2007 and 2009.

Source: Pharmacy Benefit Management Institute. 2009–2010 Prescription Drug Benefit Cost and Plan Design Report

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.