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EMD Serono Specialty Digest II

By April 30, 2013Commentary

In our ongoing look at the EMD Serono Specialty Digest, we look today at the benefit management trends.  (Specialty Digest)  More plans are planning to add cost share tiers and coinsurance for drug benefit specialty compounds and they are planning for more cost-sharing in the medical benefit as well.  A minority of plans either do or are looking at allowing 90 day supplies.  Prior authorization has become near universal and the use of electronic portals for prior authorization is gaining steam.  Plans are also taking steps to ensure use of preferred products.  The group within a plan that is responsible for utilization management differs and often depends on whether it is a drug or medical benefit, but plans say they recognize the need for more consistent and singular management of these compounds. PBMs are making some headway in managing specialty drugs for their clients with about a quarter of the plans using them in 2012.  In regard to medical benefit drugs, plans are trying to get basic NDC claims data, get the patient to use a preferred site of care, be able to do claims repricing with a fee schedule and contract for rebates.  There are over 20 categories of specialty drugs with alternatives, so that there can be a preferred medicine.  Almost all plans have at least one category  with a preferred product and the trend is to add more.  To ensure use of preferred products, plans are blocking the use of manufacture coupons on non-preferred ones.  In terms of provider reimbursement, while AWP methodologies are most common, provider capitation in some categories is growing.  Commercial plans are reimbursing providers at a higher rate than Medicare and Medicaid plans do.  Plans are also considering having preferred infusion networks and leveraging 340B pricing.

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