Insurers' strategies for managing the use and cost of biopharmaceuticals

Health Affairs

Volumn 25, Issue 5, 2006, Pages 1205-1217

  Robinson, James C ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

DRUG COST; DRUG INDUSTRY; ECONOMICS; HEALTH INSURANCE; HUMAN; MANAGEMENT; PHARMACEUTICS; PUBLICATION; REVIEW; UNITED STATES;

BIOPHARMACEUTICS; DRUG COSTS; DRUG INDUSTRY; FORMULARIES; FORMULARIES AS TOPIC; HUMANS; INSURANCE, PHARMACEUTICAL SERVICES; PRACTICE MANAGEMENT, MEDICAL; UNITED STATES;

EID: 33749325803     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.25.5.1205     Document Type: Review

References (20)

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6. This paperwas based on a review of the available literature on health plan strategies plus interviews with executives and managers with responsibilities for pharmacy services, medical management, contracting, pharmacy and therapeutics committees, specialty drug distribution, and other functions at Kaiser Permanente; WellPoint;UnitedHealthcare; and Blue Cross and Blue Shield plans in California, Pennsylvania, Oregon, Washington, and Minnesota. Additional information was obtained from interviews with biotechnology manufacturers, drug distributors, investment analysts, and industry consultants.
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9. In rheumatoid arthritis, for example, while the self-injected Enbrel was excluded from only 1 percent of formularies (and the office-infused Remicade was covered under traditional Medicare as incident to the professional practice of medicine), Humira was excluded from 20 percent and Kineret from 46 percent of formularies. E. Wang, Y. Werber, and R. Rapaport, "Biotechnology: Implications of Medicare Part D Formularies for Key Biotech Drugs" (New York: Citigroup Global Markets, 1 December 2005).
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11. BSC prior authorization for psoriasis requires diagnosis by a dermatologist or rheumatologist, age greater than eighteen (FDA label), moderate-to-severe disease for at least one year and covering a significant extent of body surface, attempted treatment but inadequate response to ultraviolet light therapy (unless contraindicated), treatment but inadequate response to disease-modifying drugs such as methotrexate or cyclosporine, and reevaluation after initial treatment of twelve weeks (compared with one year for rheumatoid arthritis).
12. The BSC prior authorization criteria include prescription by an allergist or pulmonologist; documented history of persistence formore than one year; prior use of standard therapies (Xolair should not be used as first-line therapy); inadequate response during the past year, as evidenced by asthma-related emergency room visit, inpatient admission, or unscheduled outpatient visit; high immunoglobulin level (as specified by the FDA); documented prior use ofmaximum tolerated inhaled steroids (FDA label); and restriction to nonsmokers. Approval is for six months, with subsequent extension if the patient has complied with the therapy regimen and shows evidence of improvement.
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