With specialty drugs being adjudicated under both the pharmacy benefit and the medical benefit, health plans can run the risk of incentivizing members to choose a drug based on their out-of-pocket cost share. According to data from The Zitter Group, 35% of 40 payers that have a cost-sharing level disparity between the two benefits said they were doing nothing to address that disparity. And of the 65 payers with a disparity in the prior-authorization application between the two benefits, 48% said they were taking no action to focus on the unequal approaches.
At a Jan. 26 AIS webinar, Lee Goldberg, the senior manager of syndicated research at The Zitter Group, pointed out that there could be “some type of perverse incentive for patients to try to game the system and get their drugs through the medical benefit.”
He noted that the percentages of plans doing nothing to equal out cost sharing and prior auths is consistent with survey results from 2009 and 2010.
“It’s surprising,” he said, that some payers “are not trying to make more of an even playing field.” However, said Goldberg, these payers “may think the controls they have in place [to manage specialty therapies] are enough.”
Are you surprised at the 35% and 48%? And if you’re a payer, how do you approach equalizing management of specialty drugs across the medical benefit and the pharmacy benefit?
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