Managed Care - November 2008 - (Page RSV17)

References AAP (American Academy of Pediatrics). Respiratory syncytial virus. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Redbook: 2006. Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2006:560–566. Disclosure: Albert Tzeel, MD, MHSA, has no real or apparent conflicts of interest with respect to companies, organizations, or proprietary products mentioned in this article. Health Plan Pharmacy Director: Considerations for Treatment and Management of RSV Disease DOUGLAS S. BURGOYNE, PHARMD, RPH President, Scrip World, Salt Lake City Along with human growth hormone and factor VIII, palivizumab (Synagis), an approved humanized monoclonal antibody to prevent respiratory syncytial virus (RSV) infection, was among the first drugs to be managed by health plans as a specialty drug. Specialty drugs are the high-cost biologics and injectables that often can blur the line between a medical benefit and a pharmacy benefit. Because of their high cost, health plan pharmacy directors want to be certain that specialty drugs are used at the right time by the right population. I recommend that physicians notify payers of the number of patients for whom they expect to provide palivizumab immunoprophylaxis and precertify the PAs for those patients well before the anticipated start of the season. This practice will allow both the MCO and the physicians to be prepared for the oncoming RSV season. The Centers for Disease Control and Prevention (CDC) defines the onset of the RSV season as the first of two consecutive weeks in which the median percentage of positive tests for RSV antigen is 10 percent or greater (CDC 2007). In some locales in Utah, we use a threshold of five confirmed cases within seven consecutive days Preparing for the RSV season The RSV season usually begins in November to determine season onset. However, even if and extends through March, although there is local historical data show that the RSV season DOUGLAS S. great geographical variability (AAP 2006). For usually does not begin until December, and BURGOYNE, a health plan pharmacy director, the challenge even if the threshold for season onset has not PHARMD, RPH is to budget for the inevitability of the RSV seabeen reached by then, some payers have agreed son on the basis of historical data. We at Scrip World rigwith physicians that immunoprophylaxis should be initiated in November. Initiating therapy in November, orously review prior authorization (PA) requests, espeeven without meeting the threshold criteria, recognizes cially at the beginning of an RSV season, to allow for the very real possibility that the season may last longer than an agreement between the payer and the physician that immunoprophylaxis will occur eventually, and that it is usual. If we fail to keep palivizumab utilization within better to set a definite start date for reimbursement rather budget during the first RSV season, we will be even more than to wait until physicians are inundated with cold and constrained during the following season. For example, if flu season patients, not to mention the increased risk of historical data for the previous 5 years show that the exposure to RSV associated with the holidays. PhysiRSV season in a given geographical area begins Nov. 15, cians need time to prepare and to schedule and effectively deliver RSV immunoprophylaxis to their patients and not Douglas S. Burgoyne, PharmD, RPh, is president of Scrip World, expose their patients unnecessarily to RSV infection. a pharmacy benefit management company that specializes in assisting midsize self-funded employers control their pharmacy expense. Burgoyne previously was manager of pharmacy services for IHC Health Plans. He received both his bachelor’s and doctor of pharmacy degrees from Midwestern University, Chicago. Burgoyne has served on the Academy of Managed Care Pharmacy legislative, membership, and program planning and development committees. Need for RSV guidelines When an infant is in a neonatal intensive care unit (NICU), it is critical for the hospital to work with the payer to make certain that the PA for immunoprophylaxis is received before the infant is discharged. A difficult situation for an MCO arises when an infant has re- SUPPLEMENT / RSV 17

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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