title: Managing biotechnology in a network-model health plan: a U.S. private payer perspective.
abstract: 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.
authors.affiliation: Premera Blue Cross in Mountlake Terrace, Washington, USA. john.watkins@premera.com
authors.forename: John B
authors.initials: JB
authors.lastname: Watkins
authors.forename: Sanchita Roy
authors.initials: SR
authors.lastname: Choudhury
authors.forename: Ed
authors.initials: E
authors.lastname: Wong
authors.forename: Sean D
authors.initials: SD
authors.lastname: Sullivan
mesh_terms: 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
chemical_list: D001688:Biological Products