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What Are Managed Markets for Pharma?
Managed markets customers for Pharma are health care organizations with processes (drug coverage policies and management techniques) to ensure that all appropriate patients who would benefit get timely and sustained access to innovative pharmaceuticals at a fair price.
Managed markets organizations include:
Payers
Provider organizations
Employers
Intermediaries, such as pharmacy benefit managers (PBMs)
What are Managed Care Providers?
assist in the process of managing healthcare goods and services on behalf of payers
a. Managed Care Organizations (MCOs)
b. Pharmacy Benefits Managers (PBMs)
What are some characteristics of self-funded health plans?
- The employer assumes all financial risk
- The employer may pay an MCO to manage the care and administer the benefits
- The employer’s expenses for healthcare vary based on utilization
what are some functions that are typically associated with MCOs?
- Participate with pharmacy benefit managers in the creation of formularies.
- Assist in the process of managing healthcare goods and services.
What are the three leading US wholesalers?
AmerisourceBergen, Cardinal, McKessen
Which of the following mechanism might a pharmaceutical or biotech company use to obtain a favorable formulary position with an MCO?
Rebates or price concession
Describe Medicare Part A
Free hospital insurance
- Helps cover inpatient care, hospice care, and some home health care
- Covers drugs while patient is receiving in-hospital care
- Covers drugs used in skill nursing facilities if the nursing home stay is incident to hospitalization
- Most don’t pay premiums
- Do pay deductibles when admitted as in-hospital patients
- HCPs can form accountable care organizations (ACOs) to coordinate the care provided to Medicare free-for-service beneficiaries
Describe Medicare Part B
“Traditional” or “Original” Medicare- Medical benefits covered on an outpatient basis- Optional medical insurance
- Ilumya is covered under this because we are covered under medical benefits not prescription
- Optional- must pay both monthly premiums and a deductible
- Medically necessary physician services, outpatient care, PT, OT
- Covers preventive services
- Covers drugs administered in physician offices
- Covers annual wellness visit
- Quality Payment Program: designed to help improve quality of care while reducing the administrative burden on HCPs
Describe Medicare Part C
Medicare Advantage- private health plans
- Allows beneficiaries to enroll in private health plans to receive medicare benefits
- Eligible for Medicare Advantage if they are enrolled in Part A and Part B
- Often include vision and dental, WW coverage, urgent and emergency care, fixed costs, and limits on out-of-pocket expenses
Describe Medicare Part D
Outpatient prescription drug benefit. This is not medical insurance. Ilumya is only covered under medical insurance bc its HCP administered
- Eligible if entitled to benefits under Part A
- Pay a monthly premium along with cost sharing amounts for each prescription
- Consists of three stages
1) Initial coverage
2) Coverage gap “donut hole”
3) Catastrophic coverage
What medicare is Ilumya covered on?
Medicare Part B- because this plan covers drugs administered in physician office
What is an MCO?
Managed Care Organization- outside organization that manages claims for the health insurance company (aka the payer) assist in the process of managing healthcare goods or services on behalf of payers. Develop drug formularies to help determine proper utilization.
Access vs coverage?
coverage is if the drug is covered, and access everyone can get bc if its not covered the patient can get drug for free (“early access program”- we dont get paid on this)
