Magazine article Drug Topics

Value 'More Important' Than Cost in Drug Coverage Decisions

Magazine article Drug Topics

Value 'More Important' Than Cost in Drug Coverage Decisions

Article excerpt

Viagra (sildenafil, Pfizer) may be better remembered by many Americans as the subject of late-night comedy routines, but a new study suggests the blockbuster drug may prove to be a landmark in prescription drug coverage. It called into question the methods insurers use to decide which products to cover, and to what extent they cover them. It also revealed that pharmacy benefit managers have a hand in helping payers and insurers plot their strategies.

In addition to Viagra, the study incorporated coverage decisions on Zyban (buproprion HCl, Glaxo Wellcome), Enbrel (etanercept, Immunex Corp.), and Celebrex (celecoxib, Pfizer).

Though it may surprise many detractors of managed care, "value judgments, rather than cost, seem to play a central, though largely unspoken, role in these coverage decisions," wrote Karen Titlow, M.A., and the other authors.

The study, Drug Coverage Decisions: The Role of Dollars and Values, was conducted by the Clinical Bioethics Department at the National Institutes of Health's Clinical Center and the Agency for Health Research & Quality. It took into account coverage decisions and the processes 53 insurers used in making those decisions. The plans participating in the study were diverse in size and region.

Just two of the organizations excluded Enbrel from their formularies, and even they would provide coverage if a physician requested it for a patient. COX-2 inhibitors, including Celebrex, were-covered by 92% of the insurers in the study; those that did not cover it made exceptions for medical necessity. At least some coverage of Viagra was offered by 72% of the companies. Barely half of the study sample covered Zyban, though not-for-profit organizations were nearly twice as likely to offer coverage.

Cost-cutting efforts regarding the four products varied from plan to plan. "Coverage of Enbrel and Celebrex was limited through strategies such as prior authorization to encourage medically appropriate use of these agents, whereas coverage of Viagra and Zyban was limited predominantly through generalized exclusion or through restrictions on quantity or duration of use," the authors noted.

PBMs provided a variety of services to help some of the plans reach their conclusions. Nearly a third of the respondents said they used PBMs for literature review, prospective/retrospective drug utilization review, cost-effectiveness data, and recommendations for disease management programs. …

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