Managing Pharmacy Benefits In Managed Care

管理保健组织和健康保险公司面临的主要难题之一是管理药房福利。许多新药正在推出，药品价格快速上涨，支付药房成本的压力很大。这种两难境地在围绕伟哥报道的争议中表现得最为明显。数据收集已完成，并进行了分析。这项研究考察了保险公司做出的承保决定以及在做出这些决定时使用的信息和流程。53个不同规模、税收状况和地区的组织被问及他们对四种有争议的新药的政策：伟哥、Enbrel、Zyban和Celebrex。Enbrel和Celebrex比伟哥和Zyban更有可能被覆盖。此外，Enbrel和Celebrex的覆盖范围有限，通过事先授权等战略，鼓励医学上适当使用这些药物，而伟哥和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来限制。价值判断，而不是成本，似乎在这些覆盖决定中发挥着核心作用，尽管很大程度上没有言明。研究已经完成。

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.