Drug coverage decisions: the role of dollars and values.
Given the increasing costs of pharmaceuticals today, it is important to understand how pharmacy benefits decisions are made and the role of cost and values in these decisions. 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.
Titlow
K
K
Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
Randel
L
L
Clancy
C M
CM
Emanuel
E J
EJ
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000191:economics; D018687:Antidepressive Agents, Second-Generation / Q000191:economics; D001294:Attitude to Health; D016642:Bupropion / Q000191:economics; D000068579:Celecoxib; D016861:Cyclooxygenase Inhibitors / Q000191:economics; D003659:Decision Making, Organizational; D016527:Drug Costs / Q000706:statistics & numerical data* / Q000639:trends; D011307:Drug Prescriptions / Q000191:economics*; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000191:economics; D019458:Insurance Coverage / Q000458:organization & administration*; D007349:Insurance, Health, Reimbursement / Q000191:economics*; D007783:Lactones / Q000191:economics; D016134:Organizational Policy; D010726:Phosphodiesterase Inhibitors / Q000191:economics; D010879:Piperazines / Q000191:economics; D011687:Purines; D011720:Pyrazoles; D018124:Receptors, Tumor Necrosis Factor; D000068677:Sildenafil Citrate; D013449:Sulfonamides / Q000191:economics; D013450:Sulfones; D014481:United States
D000894:Anti-Inflammatory Agents, Non-Steroidal; D018687:Antidepressive Agents, Second-Generation; D016861:Cyclooxygenase Inhibitors; D007074:Immunoglobulin G; D007783:Lactones; D010726:Phosphodiesterase Inhibitors; D010879:Piperazines; D011687:Purines; D011720:Pyrazoles; D018124:Receptors, Tumor Necrosis Factor; D013449:Sulfonamides; D013450:Sulfones; D016642:Bupropion; C116926:rofecoxib; D000068677:Sildenafil Citrate; D000068579:Celecoxib; D000068800:Etanercept