Less than half of employers have specialty prior authorization programs under medical benefits, study finds
PLANO, Texas — Management of specialty drugs under the medical benefit continues to trail management under the pharmacy benefit, according to a new report by the Pharmacy Benefit Management Institute.
The "2013 Specialty Drug Benefit Report," sponsored by Walgreens Specialty Pharmacy, found that 49% of employers had prior authorization programs for specialty drugs under the medical benefit, but 84% had them under the pharmacy benefit, while one-quarter of plans reported having no cost share for specialty medications under the medical benefit, and less than 20% were receiving rebates under medical, compared with 69% under pharmacy.
"At the core of this management gap is employers’ lack of visibility into the medical spend," PBMI executive director Brenda Motheral said. "Less than 1-in-4 employers reported being able to track specialty spend under the medical benefit, which is the foundation for active management."
The report was based on a survey of more than 300 employers representing 17.6 million members. It also found that more active management was observed for specialty drugs covered under the pharmacy benefit, including 44% of employers who had separate co-pay tiers for specialty drugs, compared with 36% a year ago. Meanwhile, step therapy adoption under the pharmacy benefit changed from 61% to 58%, and employers that limited specialty quantities to a 30-day supply grew from 58% to 67%. At the same time, knowledge of specialty drug management remained low, with 11% of employers self reporting a low level of understanding, along with 70% reporting a moderate level and 19% reporting a high level. Among small employers, 38% were unsure if they received specialty rebates under pharmacy, and nearly 40% of respondents overall were not sure which site of care had the lowest cost under the medical benefit. Employers also reported the greatest interest in learning more about specialty medical management and specialty co-pay assistance programs.
Anthem suspends controversial Calif. mail-order specialty pharmacy policy
NEW YORK — Anthem Blue Cross will indefinitely suspend a policy that would require many specialty pharmacy patients in California, most of them HIV patients, to receive their drugs via mail order in order to receive coverage for them, drawing criticism from patients and retail pharmacies.
In November and December, thousands of Los Angeles patients covered by Anthem Blue Cross received letters stating that starting Jan. 1, 2013, their drugs would only be covered if they obtained them through CuraScript, a mail-order pharmacy owned by PBM Express Scripts, while those who continued to use retail pharmacies would have to shoulder the full cost of their drugs. The date for the new policy to take effect was later postponed to March 1.
On Jan. 11, the consumer group Consumer Watchdog and law firm Whatley Kallas filed a class-action suit against Anthem on behalf of the patients, alleging that the policy discriminated against HIV patients by only forcing them to use mail order, while allowing other subscribers to use the pharmacies of their choice, thus violating California’s Unruh Civil Rights Act.
Calling Anthem’s decision to suspend the policy a precedent-setting action, the Law Offices of David Balto, which also had advocated on behalf of the patients, said it marked the first time consumers and pharmacies had been able to force an insurance company or PBM to reverse its mandatory mail-order policy.
"Anthem’s actions would have harmed thousands of vulnerable HIV patients, preventing them from receiving the first-rate health care they need and deserve," Balto, a former policy director for the Federal Trade Commission under the Clinton administration who brought some of the first cases against PBMs, said. "Study after study has demonstrated that pharmacies that specialize in serving HIV patients deliver better service, improve health care and lower healthcare costs. This is a landmark achievement in consumers’ and pharmacies’ ongoing battle against restrictive healthcare networks. Anthem’s decision to suspend their policy preserves patients’ choice and will need to better healthcare results."
Anthem had defended the policy, saying it would help moderate healthcare costs and saying that home delivery of prescription drugs could improve medication compliance.
"In response to feedback that has been conveyed by our members, which we are in the process of evaluating, we are delaying the March 1 changes in the specialty pharmacy program," Anthem spokesman Darrel Ng told Drug Store News. "We value the input of our members."
Pharmacists and the battle to boost adherence
Two-hundred-ninety billion dollars. That’s the number often thrown around when health experts talk about what medication nonadherence costs patients, insurers, health plan payers and the U.S. economy every year. And of course, dollar estimates say nothing about the impact that nonadherence has on patients and their families in higher chronic and acute disease rates, reduced quality of life and shortened lifespans.
So the failure by patients to take their meds as prescribed is a big deal. And it’s gotten a lot of attention from payers in the last couple of years because it’s one of the most obvious levers to pull as public and private health plan sponsors struggle to get a grip on the astronomical and still-expanding cost of health care in the United States.
Pharmacists, of course, are right in the middle of that effort. Boosting Americans’ adherence to the prescription therapies prescribed by their doctors has become mission critical to many pharmacists, and it’s one of the clearest ways they can contribute directly and measurably to the health system’s massive effort to contain costs.
That’s why it was welcome news when CVS Caremark announced earlier this month that it’s expanding its Pharmacy Advisor program to cover an additional five chronic conditions, including asthma, breast cancer, chronic obstructive pulmonary disease, depression and osteoporosis. As DSN senior editor Antoinette Alexander reports, “The condition-based program alerts pharmacists when patients are not adherent to their medication regimens or have a gap in care, allowing them to intervene with patients and communicate with their physicians in real time.”
Up to this point, Pharmacy Advisor focused on patients with diabetes or cardiovascular conditions. But even with that limited pallet of services, CVS pharmacists have already conducted more than 3.8 million interventions through the service, Alexander reports. They also direct patients with chronic conditions who are enrolled in the program to existing disease management programs where they can find other support resources.
Pharmacy Advisor is about “the coordination of care for individuals living with chronic conditions,” according to Troyen Brennan, EVP and chief medical officer for CVS Caremark. And pharmacists, he said, “play an important role in and understand how critical medication adherence is in supporting their patients.”
Do you agree? And if you’re a practicing pharmacist in a community or hospital setting, or a pharmacy student, how much attention is the adherence issue getting in your workplace or classroom? As always, your feedback is welcome and appreciated.