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Executive Summary

BLUE CROSS/BLUE SHIELD ASSOCIATION MAY BE HEADED TOWARD DRUG COVERAGE reviews as part of a change in its approach to paying for drugs used by beneficiaries. The executive director of technology management for the Blue Cross and Blue Shield Association, Susan Gleeson, told a September 15 seminar in Washington, D.C. that the national association is beginning to revise its approach to drug coverage. "We have started and we will be going into a rather major process to re-evaluate what our policy should be" toward drug coverage. The association has formal procedures for decisions on medical device coverage through two processes: Technology Evaluation and Coverage (for new devices) and the Medical Necessity Program (for re-evaluation). Gleeson pointed out that neither the national organization (the Blue Cross and Blue Shield Association) nor the individual plans now evaluate drugs for coverage. The current plan contracts, in general, call for coverage of FDA-approved drugs for FDA-approved indications. She reported that there is growing interest in drug costs among the plans. Gleeson says that she is in frequent touch with the individual plans about a method for determining which products to cover. "There is certainly an outcry," Gleeson observed, "about what are we going to do about drugs" She said that the association receives calls "once-a-week" from the plans urging decisions on drug payments. Part of the catalyst for the concern about drug coverage among the Blues has been the TPA/streptokinase price differential. Gleeson called the anti-thombolytic drug class "one of the most dramatic examples" of the pressure for cost-effectiveness (comparative) analyses of medical products. The current interest in thrombolytic care and the price differentials in that class may bump drugs to the top of the list of technologies facing cost-effectiveness evaluations. Gleeson predicted that some of the first cost-effectiveness decisions for coverage may come in the drug field. Noting that technology assessment had been "fairly dormant" in terms of drug therapies in the past, Gleeson said, "there will be a focus [on drugs] and clearer information about what insurance is going to do about drugs." While the Blues national association is reviewing its hands-off policy towards drug coverage decisions, the separate, local plans may take interim measures. Gleeson, for example, forecast changes in the benefit contract language to permit drug cost-effectiveness reviews by the local plans. Gleeson said that the individual Blue Cross/Blue Shield plans may begin going back "in 1989 and redrafting the (benefit) contract language to say specifically what [drugs] they are going to pay for." The new contracts may also deal with the issue of Blue Cross drug coverage for unlabeled indications. Another possible short-term response to the price differential, Gleeson suggested, may be "creative things" such as negotiated price contracts or volume purchasing deals by individual plans.

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