Real-World Examples of Benefit Integration Management

San Diego—During a session at the AMCP meeting, Jennifer Schauer, PharmD, clinical pharmacist, University of Wisconsin Hospital & Clinics, Unity Health Insurance, Madison, Wisconsin, and Elizabeth Kelly, PharmD, clinical manager, pharmacy services, Blue Cross Blue Shield of Michigan, discussed the development and implementation of integrated medical and pharmacy benefits among their respective organizations.

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Dr. Schauer began the presentation by discuss the program at Unity Health, which is a provider-owned, regional health maintenance organization in southern Wisconsin that operates as an integrated delivery system with the University of Wisconsin serving 170,000 medical benefits and more than 90,000 pharmacy benefits.

She noted barriers to effectively integrating medical and pharmacy benefits, including:

            • Complex claims processing system

            • Providers do not know how to bill

            • Provider systems are inadequate to alert need for prior authorization

            • Service provided prior to current coverage is unknown

            • Fiscal knowledge is limited

            • Fee-for-service thinking

Dr. Kelly continued the presentation by examining the Blue Cross Blue Shield of Michigan experience. A total of 4.4 million covered lives reside in the state of Michigan in addition to 1.3 million people in other states, making this a large preferred provider organization.

She addressed the steps taken to incorporating medication into the benefits formulary. For example, once a specialty drug is FDA-approved, a pre-specialty drug workshop is held, following by a specialty drug workshop, than a pharmacy & therapeutics committee hearing, and a joint uniform medical policy for the medical benefit, specifically. After that, deciding on adding a drug to the medical prior authorization program includes determination of the drug class, off-label potential, step-therapy potential, volume of prior authorization requests, barriers, and cost.

Noted barriers include volume and staffing, rebates impacted, whether the drug is hospital administered or part of a hospital package, urgency of the drug administration, public relations, and J code versus national drug code designation.

Dr. Kelly also indicated the real-world results for Blue Cross Blue Shield of Michigan in terms of prior authorization for their medical and pharmacy benefits (Table).—Kerri Fitzgerald