MCOs' Shifting Control Over Office-Administered Products from Medical to Pharmacy Benefit, Particularly Affecting Rheumatoid Arthritis Therapies

BURLINGTON, Mass., July 31, 2013 /PRNewswire/ -- Decision Resources, one of the world's leading research and advisory firms for pharmaceutical and healthcare issues, finds that 68 percent of surveyed managed care organization (MCO) pharmacy directors either currently or plan to transition specialty product coverage from the medical benefit to the pharmacy benefit for office-administered products, particularly affecting therapies in rheumatoid arthritis. This transition, which is slated to be completed in 2015 or later after many of the policies in the Affordable Care Act begin to take effect, comes as MCOs deal with a cost trend for specialty drugs that far exceeds those for small molecule therapies. As a result, MCOs are implementing strategies to control access to specialty therapies in rheumatoid arthritis, multiple sclerosis and oncology.

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The Physician & Payer Forum 2013 report entitled Market Access for High-Cost Biologics in Multiple Sclerosis, Oncology, and Rheumatoid Arthritis also finds that 85 percent of surveyed plans have some utilization restrictions in place for specialty drugs, particularly prior authorization for therapies covered under the pharmacy or medical benefit. However, other restrictions are slated to increase in use. In the next 12 months, 63 percent of surveyed payers expect to have site of care restrictions in place, while 66 percent will have preferred and non-preferred specialty tiers. Furthermore, some MCOs plan to eliminate grandfathered coverage for specialty therapies while 52 percent anticipate restricting use of copay coupons for non-preferred specialty agents.

In addition, surveyed neurologists, rheumatologists and payers report notable restrictions around specialty therapies treating MS and RA, reflecting the launch of newer premium-priced therapies. Of note, however, MCOs' traditional laxer restrictions around oncology may be giving way to greater management by payers, particularly through the use of clinical pathways and companion diagnostics.

"Increased complexity in benefit design is impacting all pharmaceuticals, and plan members continue to have increases in financial responsibility. This is especially true for higher cost specialty drugs which are covered more often in a co-insurance tier," said Senior Director Brenda Cole. "In addition, competition in the form of both new brands and generic introductions are allowing MCOs increased leverage with manufacturers, especially in the MS and RA markets, but also in some oncology markets. Payers have been talking about increasing restrictions and using differential co-pays to lower costs with specialty drugs and this report shows how they are taking action and what trends are likely to continue and evolve."

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SOURCE Decision Resources