Managing biotechnology in a network-model health plan: a U.S. private payer perspective.
Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology.
Watkins
John B
JB
Premera Blue Cross in Mountlake Terrace, Washington, USA. john.watkins@premera.com
Choudhury
Sanchita Roy
SR
Wong
Ed
E
Sullivan
Sean D
SD
D001688:Biological Products / Q000191:economics*; D001709:Biotechnology / Q000191:economics*; D054598:Blue Cross Blue Shield Insurance Plans / Q000458:organization & administration*; D019090:Case Management; D017723:Drug Utilization Review; D005569:Formularies as Topic; D006801:Humans; D007356:Insurance, Pharmaceutical Services; D014481:United States
D001688:Biological Products