Private Insurance
To manage growing drug plan costs, private payers are implementing several plan designs to manage specialty drug use:
- Special or prior authorization: A patient or their physician must submit additional information for the insurance carrier to review to ensure the patient meets specific criteria before coverage is confirmed. The review could include clinical information, prior treatments and/or diagnosis.
- Case management: Case management is like special or prior authorization but requires much more information to be provided to the insurance company’s case manager who will review the treatment plan and consult with the physician. Case managers may recommend an alternate treatment or monitor the patient to ensure that they obtain the best possible outcomes.
- Preferred pharmacies: Some private plans require patients to use a pharmacy or chain exclusively, and others cover more of the cost for patients who use these pharmacies. Some insurers have partnered with specialty pharmacies for exclusive distribution of biologic treatments to patients.
- Managed formularies: Their drug plans pay for a predetermined selection of effective and affordable drugs. Their insurance carrier or pharmacy benefit manager will manage the formulary on behalf of the employer.