Abstract
Specialty pharmacy (SP) products treat specific, complex chronic diseases and are costly; require reimbursement and handling assistance/training, have unique/limited distribution processes; frequently have patient-adherence programs. In 2014 SPs accounted for 33% of spending (up from 2009=23%). Diagnostic/genetic tests identify/predict diseases and treatment response. Understand US health plans/insurers/PBMs management of SPs, diagnostic and genetic tests. Online survey of Managed care (MC) medical and pharmacy directors from public/private-plans with multiple member-types on: advisor+plan information; specialty-pharmacies/pharmaceuticals, and genetic/diagnostic tests. MDs represented 54% of respondents. Plans were: 39.6%=local; 35.4%=National; 25.0%=regional. 53.7% of plans restricted SP providers: the majority restricted services to a small set under contract (63.0%), 17.4% allow any SP; and 6.5% only restricted products available through multiple specialty pharmacies. Plans covered clinician administered products (CAPs, i.e., injections/infusions) under the medical-benefit (MB=67.3%); none exclusively under the pharmacy-benefit (PB=0%); 32.7% based on cost thresholds. Changes for CAPs: not expected (72.9% of plans), expected before 12/16 (18.8%) and 12/18 (2.1%). Oral Biologics (OBs) were managed under the PB 78.3%; the MB (10.9%); based on cost thresholds (10.9%). Expectations for OB benefits: no change (71.1% of plans), currently changing (11.1%); before 12/16 (13.3%) and 12/18 (4.4%). SP+OB copays vary by group/benefit design and are shifting from fixed to %-copays. SPs were a top current/future concern. In 2013, genetic tests (GTs) were covered in all cases (59.1% of plans); not covered (20.5%) and below threshold (20.5%) by 2015, GTs were expected to be covered in all cases (63.4%); not covered (9.8%); and threshold-based (26.8%). GT coverage was highest for oncology (92.9%); OB/GYN (83.3%); cardiovascular (50%). Disease marker tests were covered in all cases (86.7%), not covered (4.4%), and 8.9% threshold based. Coverage for therapy response tests: all cases (76.6%), no-cases (10.6%); and 12.8% threshold-based. Testing and specialty pharmacy/pharmaceutical expenditures are expected to grow and require appropriate coverage.
Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
