Medical Benefit vs. Pharmacy Benefit

Ok managed care reps....Many trade publications have articles from time to time claiming that there is or will be a trend toward moving all Rx's over to the Pharmacy Benefit so Plans can have a more integrated view of pharmacy spend. My questions to you are:

Are you seeing this trend in your daily interactions with plans and, if so, where do you think that will leave specialty biotech distributors who's book of business is largely dependent upon physicians who buy & bill?

 

It is not that simple-The movement from Medical to Rx will depend on the economics. At an ASP+6% rate, specialty pharmacy is more expensive. MCOs say they want to do this, but most of them cannot execute.

 

The trend is towards integrated medical and pharmacy benefits where drugs are priced identically across both the pharmacy and medical benefits. It is already occuring in health plans with in-house PBMs and in some outsourced PBM partnerships such as the ones between more than a dozen Blue Cross plans and Prime Therapeutics. It is already possible for a pharmacy benefit claim to require a medical diagnosis but still be adjudicated at the point of sale such as when human growth hormone is provided as a retail benefit but requires known growth hormone deficiency. And whether self adminsitered and processed as a pharmacy claim or provider adminstered and processed as a medical claim it is also possible to achieve pricing parity. The medical vs. pharmacy benefit question is out of date except for the remaining carve-out pharmacy benefits with large ASO groups and PBM carve-puts are eroding.