Managed Care - November 2008 - (Page 23)

But notwithstanding those advantages, the complexity of a full range of behavioral health benefits — especially for chronic mental illnesses — means that state and regional plans will probably continue to rely on vendors. It is too early to tell what the federal government’s recently enacted parity legislation, which does not take effect for a couple of years, will do to the market, but some experts say that carve-outs will remain important in this field for some time. DRUG BENEFITS Whether or not that is also true for pharmacy benefits, including specialty pharmacy, is unclear, however. Health plans, even several of the regional plans that are engaged in Medicare Part D, do appear eager to bring their drug benefits in-house — primarily because the value of integration of drug and medical services is not at all unclear. “PBMs simply do not have access to diagnostic data,” says Plans use a variety of management techniques Drug benefit plans include a variety of drug inclusions, exclusions, and utilization management tools to manage drug mix, and employers are using a broad range of utilization management tools in their plan designs for all diseases and conditions. Implementing each tool varies for five highly prevalent diseases that are commonly treated with drug therapies. More employers are using disease management in 2008 than last year to manage diabetes than to manage asthma, high blood pressure, and high cholesterol. Percentage of employers using utilization management tool I ≤20% I 20–30% I 30%–40% I 40%–60% Asthma 42.1% 17.6 63.2 15.4 31.7 11.5 34.7 11.5 26.2 18.4 27.8 48.8 39.0 24.0 30.1 I ≥60% Depression 36.8% 23.5 35.8 27.7 28.3 23.1 16.0 30.8 33.3 16.5 34.0 52.4 42.0 25.0 27.7 Diabetes 47.4% 50.0 74.5 16.9 36.7 11.5 36.0 11.5 31.0 12.0 28.4 49.4 36.0 17.0 30.1 High blood High pressure cholesterol 52.6% 32.4 55.7 18.5 33.3 19.2 26.7 19.2 35.7 12.7 25.3 49.4 38.0 29.0 33.7 42.1% 35.3 50.9 24.6 33.3 26.9 22.7 42.3 35.7 13.9 29.0 48.8 38.0 31.0 37.3 Utilization management tool Academic detailing of prescribers Copayment relief or waivers Disease management Dose optimization Face-to-face pharmacist consults Generic sampling Outbound telephone calls Pill splitting Prescriber profiling Prior authorization Quantity limits Refill too soon supply limit Retrospective drug utilization review (DUR) Step therapy Therapeutic substitution All diseases 9.6% 17.1 53.3 32.7 30.2 13.1 37.7 13.1 21.2 79.4 81.4 82.4 50.3 50.3 41.7 Source: Prescription Drug Benefit Cost and Plan Design Report, 2008–09 Edition. Pharmacy Benefit Management Institute. NOVEMBER 2008 / MANAGED CARE 23

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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