Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Correspondence
  • Published:

Medicare formulary coverage for top-selling biologics

Nature Biotechnology volume 27, pages 1082–1084 (2009)Cite this article

To the Editor:

'Biologics' are therapeutics produced through recombinant DNA technology or other biological processes. The number of available biologics and expenditures for them have increased dramatically in recent years. Although insurance coverage policies must balance patient and societal needs of access and affordability, insurers may also adopt strategies to manage the use of these expensive drugs. Such strategies include a more complex tiered formulary (drugs are divided into “tiers,” with the first tier typically representing generics at the lowest level of patient cost-sharing, and a higher tier requiring higher patient cost-sharing), prior authorization (requiring physicians to obtain approval from the health plan before prescription for coverage) and the use of specialty pharmacy vendors1,2,3. Despite the growing importance of biologics, little is known about their coverage, cost-sharing and management tools, or how they vary across drug characteristics. Current evidence is limited to studies of selected health plans2,3, geographical areas4 or diseases5.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Adams, K.T. Biotechnol. Healthcare. 3, 28–35 (2006).

    Google Scholar 

  2. Mullins, C.D., Lavallee, D.C., Pradel, F.G., DeVries, A.R. & Caputo, N. Health Aff. (Millwood) 25, 1332–1339 (2006).

    Article  Google Scholar 

  3. Robinson, J.C. Health Aff. (Millwood) 25, 1205–1217 (2006).

    Article  Google Scholar 

  4. Tseng, C.W., Mangione, C.M., Brook, R.H., Keeler, E. & Dudley, R.A.J. Am. Med. Assoc. 297, 2596–2602 (2007).

    Article  CAS  Google Scholar 

  5. Bowman, J., Rousseau, A., Silk, D. & Harrison, C. Health Aff. (Millwood) 25, 1240–1248 (2006).

    Article  Google Scholar 

  6. Comer, B. IMS: Global biotech sales up 12.5% in 2007. (2008) http://www.mmm-online.com/IMS-Global-biotech-sales-up-125-in-2007/article/111366/.

    Google Scholar 

  7. Stern, D. & Reissman, D. J. Manag. Care Pharm. 12, 736–744 (2006).

    Article  Google Scholar 

  8. Hargrave, E., Hoadley, J. & Thompson, J. Coverage and Pricing of Drugs That Can Be Covered Under Part B and Part D (MedPAC, Washington, DC, 2007).

    Google Scholar 

  9. Huskamp, H.A., Stevenson, D.G., Donohue, J.M., Newhouse, J.P. & Keating, N.L. Psychiatr. Serv. 58, 308–310 (2007).

    Article  Google Scholar 

  10. Hargrave, E., Hoadley, J. & Merrell, K. Drugs on Specialty Tiers in Part D (MedPAC, Washington, DC, 2009).

    Google Scholar 

  11. Hoadley, J., Hargrave, E., Cubanski, J. & Neuman, T. Medicare Part D Data Spotlight: Specialty Tiers (Kaiser Family Foundation, Menlo Park, California, USA, 2009).

    Google Scholar 

  12. Walsh, B. The Tier 4 Phenomenon: Shifting the High Cost of Drugs to Consumers (AARP, Washington, DC, 2009)

    Google Scholar 

Download references

Acknowledgements

The authors are grateful for contributions to this paper from C. Hosenfeld. This study was funded by two grants to K.A.P. from the US National Cancer Institute (R01CA101849 and P01CA130818) and a grant from the Aetna Foundation (unrestricted).

Author information

Authors and Affiliations

  1. Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA

    Su-Ying Liang & Kathryn A Phillips

  2. Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA

    Jennifer S Haas

Authors
  1. Su-Ying Liang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jennifer S Haas
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kathryn A Phillips
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Su-Ying Liang.

Ethics declarations

Competing interests

S.-Y.L., J.S.H. and K.A.P. received funding from a research grant from the Aetna Foundation to study the utilization of emerging genomic technologies. J.S.H. received salary support from a research grant from Pfizer to study reporting of adverse drug events to the FDA.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Liang, SY., Haas, J. & Phillips, K. Medicare formulary coverage for top-selling biologics. Nat Biotechnol 27, 1082–1084 (2009). https://doi.org/10.1038/nbt1209-1082

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1038/nbt1209-1082

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing