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Intravenous Immune Biologics Will Suffer from the Pending Shift in Coverage from the Medical to the Pharmacy Benefit
Date:7/15/2009

NASHVILLE, Tenn. and GLEN ROCK, N.J., July 15 /PRNewswire/ -- HealthLeaders-InterStudy and Fingertip Formulary find that surveyed pharmacy directors of both national and single state plans say coverage of immune biologics will shift from a medical benefit to a pharmacy benefit by 2014, citing Centocor Ortho Biotech's Remicade and UCB's Cimzia among products that will be most affected by this shift. According to the new Formulary Forum report entitled Formulary Advantages in Immune Biologics: Tightening Payer Control Offers Opportunities for Differentiation, the majority of surveyed pharmacy directors say they currently cover Amgen/Wyeth's Enbrel and Abbott's Humira solely as a pharmacy benefit, but cover other immune biologics as a medical benefit.

The report finds that payers expect the shift of biologics from the medical benefit to the pharmacy benefit is motivated by an expectation of increased cost control. For example, 34 percent of surveyed payers currently require patients taking an IV biologic to first fail therapy with an SC biologic and will continue to enforce this requirement moving forward. An additional 38 percent of surveyed payers expect to newly implement this cost control measure over the next five years.

"Managed care organizations are looking to restrict patient access to physician-administered biologics, because these agents are harder to control in terms of cost outlays--in part due to physicians preferentially prescribing agents such as Remicade so the physician can purchase the agent at a discount relative to the reimbursement rate and thus maintain a profit margin on the procedure," said Michael Malecki, Ph.D., product manager for Formulary Forum. "Maintaining control of the supply chain will be critical to the future profitability of managed care organizations, and plans are aware of this fact. By 2014, for example, 84 percent of surveyed pharmacy dire
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SOURCE HealthLeaders-InterStudy
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