One of the major dilemmas facing managed care organizations and health insurers is managing pharmacy benefits. Many new drugs are being introduced, drug prices are rising rapidly, and the pressure to cover pharmacy costs is intense. The dilemma has been most clearly manifest in the controversy surrounding the coverage of Viagra. Data collection has been completed and analyzed. This study examines what coverage decisions insurers make and the information and processes used in making these decisions. Fifty-three organizations, differing in size, tax status, and region, were asked about their policies for four new and controversial drugs: Viagra, Enbrel, Zyban, and Celebrex. Enbrel and Celebrex were much more likely to be covered than Viagra and Zyban. In addition, coverage of Enbrel and Celebrex was limited, through strategies such as prior authorization, to encourage medically appropriate use of these agents, whereas coverage of Viagra and Zyban was limited predominantly through generalized exclusion or through restrictions on quantity or duration of use. Value judgments, rather than cost, seem to play a central, though largely unspoken, role in these coverage decisions.
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| Burton, S L; Randel, L; Titlow, K et al. (2001) The ethics of Pharmaceutical benefit management. Health Aff (Millwood) 20:150-63 |
