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Coverage Trends of Specialty Drugs Create Confusing Situations for Patients
As a result of vertical integration, health plans may have 2 different coverage policies on the medical benefit side and the pharmacy benefit side for the same drug.
The vertical integration of pharmacy benefit managers and insurers has led to strategies that have created confusing and counterintuitive situations for patients to navigate, explained James D. Chambers, PhD, professor, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center.
This transcript has been lightly edited for clarity.
Transcript
There is a trend of specialty drugs being shifted from the medical benefit to the pharmacy benefit. Why are payers doing this and what are some potentially negative consequences of this strategy?
We had a paper published last year that looked within our database of specialty drug coverage decisions, and on occasion, the same health plan had both a medical policy and a pharmacy policy for the same drug. Confusing. Even more confusing was, 15% of the time, the coverage requirements differed—so the step therapy requirements are inconsistent between the medical benefit and the pharmacy benefit. What we were trying to show with this paper is simply that this is very confusing and oftentimes counterintuitive.
Why are we seeing the merging of the medical and the pharmacy in different instances? Historically, of course, physician-administered drugs are in the medical benefit, self-administered drugs in the pharmacy benefit. White bagging and brown bagging are an attempt, I think, for an insurance company to drive patients to their own pharmacy—this vertical integration idea—in order to profit from the drug, from a pharmacy perspective, and to ensure that they're maximizing the return that they're getting from the delivery and administration off the drug. It really is a vertical integration problem.
As outlined in the paper, it's challenging for patients. It might increase waste in the system as well, and it's putting more onus on the patients to collect drugs and to organize things. The system's complicated enough as it stands. Also, it leads to inconsistencies in access, because we see that there's differences in coverage between the medical and pharmacy benefits for the same drugs. It really is a symptom, I think, of the vertical integration of the pharmacy chain in general.
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