Managing biotechnology in a network-model health plan: a U.S. private payer perspective.

Health Affairs 25(5):1347 (2006) PMID 16966732

Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology.