Managed Care


What Drugs Are Covered? Safety, Efficacy Matter

MANAGED CARE April 2000. © MediMedia USA
News and Commentary

What Drugs Are Covered? Safety, Efficacy Matter

MANAGED CARE April 2000. ©2000 MediMedia USA

Safety and medical effectiveness most determine whether a health plan will cover a new drug, according to a study in the March/April Health Affairs. Supported by the U.S. Agency for Healthcare Research and Quality, researchers polled chief medical officers or pharmacy managers at 53 plans.

The conclusions counter popular belief that price drives plans' coverage decisions. In a separate article in the same issue, the president of a Denver consulting company said MCOs whose formularies are based primarily on cost are missing an opportunity.

Formularies that rely on pharmacoeconomic evaluations, wrote J.D. Kleinke of Health Strategies Network, "will fulfill what may be managed care's most useful role ... to emerge as the broker of information to consumers about what kind of care works and what that care is worth." Drugs with no pharmacoeconomic benefit should be tagged with the highest copayments, he suggested, while those with proven cost savings "probably should be fully prepaid by the health plan."


4th Partnering With ACOs Summit Los Angeles, CA October 27–28, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014
HealthIMPACT Southeast Tampa, FL January 23, 2015