Managing Pharmacy Benefits In Managed Care

管理式医疗机构和健康保险公司面临的主要困境之一是管理药房福利。许多新药正在推出，药品价格迅速上涨，支付药房费用的压力很大。这种困境在围绕伟哥报道的争议中表现得最为明显。已完成数据收集和分析。本研究探讨了保险公司做出的承保决策以及做出这些决策时使用的信息和流程。53个组织，不同的规模，税收状况和地区，被问及他们的政策，四个新的和有争议的药物：伟哥，恩布雷尔，Zyban和西乐葆。Enbrel和Celebrex比Viagra和Zyban更有可能被覆盖。此外，Enbrel和Celebrex的覆盖范围有限，通过事先授权等策略，鼓励在医学上适当使用这些药物，而Viagra和Zyban的覆盖范围主要通过普遍排除或通过限制使用数量或持续时间而受到限制。价值判断，而不是成本，似乎发挥了核心，但在很大程度上是不言而喻的，在这些覆盖决定的作用。 研究完成。

One of the major dilemmas facing managed care organizations and health insurers is managing pharmacy benefits. Many new drugs are being introduced, drug prices are rising rapidly, and the pressure to cover pharmacy costs is intense. The dilemma has been most clearly manifest in the controversy surrounding the coverage of Viagra. Data collection has been completed and analyzed. This study examines what coverage decisions insurers make and the information and processes used in making these decisions. Fifty-three organizations, differing in size, tax status, and region, were asked about their policies for four new and controversial drugs: Viagra, Enbrel, Zyban, and Celebrex. Enbrel and Celebrex were much more likely to be covered than Viagra and Zyban. In addition, 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. Value judgments, rather than cost, seem to play a central, though largely unspoken, role in these coverage decisions. Study is completed.