HealthLeaders-InterStudy, a leading provider of managed care market intelligence, reports that while all healthcare eyes have turned to generic drug utilization as key to holding down healthcare costs, its the biologics and top-tier specialty drugs that may present a greater challenge. According to the latest Tennessee Health Plan Analysis, as specialty drugs costs have surged, insurer BlueCross BlueShield of Tennessee has enacted several measures to deal with rising costs, including shuffling these drugs to higher tiers, moving them from medical benefits to drug coverage and increasing copays.
"In almost every sense, generics and specialty drugs reside at opposite ends of the cost spectrum," states Don Mooradian, analyst for HealthLeaders-InterStudy and author of the report. "The vendors for specialty drugs are limited, leaving no option for cheaper, generic versions."
The structure and placement of specialty drugs varies within a health benefits plan. Under the BlueCross BlueShield of Tennessee specialty drug program, the intramuscular and intravenous drugs that are provider-administered are usually considered medical benefits while the subskin and oral medications that are self-administered typically are part of the pharmaceutical program. According to the report, about 65 percent of BlueCross BlueShield of Tennessee members fall under a three-tier copay system. If a specialty drug is generically available, it falls into the first tier. Some of the self-administered drugs are on the company's preferred drug list on the second tier. After that, basically, just about everything is on the third tier.
For fully insured commercial benefits, most of the specialty drugs fall into the nonpreferred category, therefore it is the highest copay tier. If members use one of the plan-contracted specialty vendors, they pay a copay, which is normally about $50. However, there is a disincentive to use retail pharmacy. For instance, if a member uses someone other than the designated specialty vendors, they will pay two times the copay for the specialty drug.
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