How are private health plans managing biopharmaceuticals?
The accelerating demand for and use of these drugs has placed increased pressure on health plans to evaluate whether the drugs are being prescribed appropriately. In response, health plans have adopted multiple strategies to manage biopharmaceutical use at the physician, manufacturer & distributor, and consumer levels. In contrast to their more restricted roles for traditional drugs, physicians often are responsible for administering as well as prescribing biopharmaceuticals. Large oncology and rheumatology practices frequently purchase these drugs from distributors or manufacturers. These drugs are administered to patients during office visits, and claims for reimbursement are submitted to the patients’ health insurers. This creates a potential conflict of interest in that physicians are paid not merely for their professional services but also for the price markups they impose on the drugs that they purchase, often referred to as “buy and bill.” Depending on the drug and condition, he
