How Do Insurers Decide What Medicines to Pay For? | NBC4 Washington
National & International News
The day’s top national and international news

How Do Insurers Decide What Medicines to Pay For?

Insurers largely use pharmacy benefits managers to set up the lists that determine how much a patient ends up paying

    processing...

    NEWSLETTERS

    The White House and Republican lawmakers spent Tuesday defending the proposed replacement for the Affordable Care Act after a report released by the Congressional Budget Office predicted a loss in coverage for 24 million Americans should the American Health Care Act pass into law. 

    (Published Tuesday, March 14, 2017)

    How do insurance companies decide what medicines to pay for and when to pay for them?

    Insurers and other payers look first at how well the drug works — not its cost — when they decide whether to cover the latest treatments, according to the nation's largest pharmacy benefits manager, Express Scripts.

    The price patients eventually pay gets determined later, when an insurance company or pharmacy benefits manager decides where a drug fits on a list of covered treatments called a formulary.

    The cost of prescription drugs has become a growing source of concern with doctors and patients, but it's not a factor considered by an independent committee used by Express Script to determine coverage of a new drug, Chief Medical Officer Dr. Steve Miller said.

    Dog Delivers Basket of Water on Baseball Field

    [NATL] Dog Delivers Basket of Water on Baseball Field

    A viral video of minor league baseball dog delivering water at a Fort Wayne TinCaps game has surfaced on Twitter.

    Video of 'Jake the Diamond Dog' was posted as the golden retriever carried a basket filled with bottled water out to the umpire between innings taken at a recent game.

    The video was posted by Indiana news station WPTA's sports anchor Zach Groth.

    Jake delivers water to umpires on the field in a basket and reportedly makes an appearance at a variety of minor league baseball games and has done so for several years.

    (Published 3 hours ago)

    That committee — 15 doctors and a pharmacist — reviews the information that federal regulators used to approve a drug and then decides whether it should be covered.

    Some payer coverage decisions come with qualifications like a requirement that patients meet specific criteria or try other treatments first. That can limit patient access. Doctors say some patients have had trouble getting a new cholesterol-lowering drug, Repatha, that costs $14,000 a year, because of the restrictions.

    Insurers largely use pharmacy benefits managers to set up the lists that determine how much a patient ends up paying. Some lists are divided into tiers, with drugs on the bottom generally being generic or least expensive. Those on the highest tier might include specialty medicines that could cost the patient hundreds of dollars even with coverage.

    Whether a drug even gets on the list can depend on whether a similar medicine is already in the market. When the ground-breaking hepatitis C treatments Sovaldi and Harvoni from Gilead Sciences debuted a few years ago, Express Scripts had to include them. They cost more than $80,000 for a course of treatment, but the drugs essentially cure a debilitating disease and they had no competition.

    But once the drugmaker AbbVie produced a third option, Viekira Pak, with a similar cure rate, Express Scripts was able to negotiate a price discount and switched to covering only Viekira Pak.

    The nation's two largest pharmacy benefits managers, Express Scripts and CVS Health Corp., both say they cover Repatha.

    Man Hit By Bus, Flung Across Sidewalk Walks Away

    [NATL] Man Hit By Bus, Flung Across Sidewalk Walks Away

    A bus in Reading, England, swerved around a corner and hit a pedestrian on June 24, sending the man sliding across the pavement. The man stood up and walked into the Purple Turtle pub without major injuries.

    (Published Wednesday, June 28, 2017)