reimbursement@wiki

 

 

See Also Technology Assessment

 

Payers' Coverage Policies, Policy Development, and Technology Assessment

• Aetna
• • Medical Clinical Policy Bulletins
  • Clinical Policy Process and Medicare Coverage Decisions (January 2005) -- Powerpoint lecture discussing development of Aetna's medical policies
• Blue Cross Blue Shield plans
• • BCBS of Tennessee
  • • Medical Policy Manual
• CIGNA
• • Medical Resources
  • • Coverage Positions/Criteria
• Harvard Pilgrim Health Care
• • Technology Assessment Policies
  • Clinical Guidelines
  • • Clinical Guidelines Program
  • Prior Authorization Medical Review Criteria
• HealthPartners
• • Coverage Criteria
• Humana
• • Coverage Development Process
  • Coverage Issues
  • • All Coverage Issues (by Name)
    • All Coverage Issues (by Revision Date)
• Tufts Health Plan
• • Medical Necessity Guidelines
  • Clinical Practice Guidelines
• United HealthCare
• • Medical Policies
  • Reimbursement Policies
• Wellpoint
• • Anthem BC
  • • Medical Policies and UM Guidelines
    • Medical Policy Formation (November 2007)
  • Blue Cross Blue Shield of Georgia
  • • Medical Policies and Clinical UM Guidelines
  • Empire Blue Cross Blue Shield
  • • Medical Policies and Clinical UM Guidelines

 

Pricing

• The Arrival of ASP, by Patrick Mullen (Biotechnology Healthcare, June 2007)

P&T Committees

• Do P&T Panels Need Cost Data? Some say prices are a distraction; others believe the committee cannot do its job without them.

CED

• Coverage With Evidence Development: Private Payers Are Watching.  A middle ground between unlimited coverage and no coverage at all, CED wasn't developed with biologic therapies in mind. But healthcare players and payers are watching CED's application carefully, as well as its effect on coverage and drug development.

Coverage Decision-Making

• Satisfying the P&T Committee's Need for More Evidence (Managed Care Magazine, October 2006)
• Health Plans' Coverage Determinations for Technology-based Interventions: The Case of Electrical Bone Growth Stimulation (December 2004)
• Cost-Effectiveness And Evidence Evaluation As Criteria For Coverage Policy (May 2004)
• Using Evidence and Cost in Managed Care Decision-Making (Health Affairs, August 2002)
• Randomized, Controlled Trials, Observational Studies, and the Hierarchy of Research Designs (June 2000)
• Managed Care Organizations' Assessment of Reimbursement for New Technology, Procedures, and Drugs (August 1999)

Data and Resources

• Managed Care Digest Series by sanofi aventis
• Managed Care magazine
• AIS Market Data (dated): Pharmacy Benefit Management

<!--[if !supportLists]--><!--[endif]-->o        Prescription Drug Copay Trends

<!--[if !supportLists]--><!--[endif]-->o        Prescription Drug Utilization

<!--[if !supportLists]--><!--[endif]-->o        PBM Market Share

<!--[if !supportLists]--><!--[endif]-->o        PBM Prescription Drug Costs

<!--[if !supportLists]--><!--[endif]-->o        Specialty Pharmacy

• AIS Market Data: Managed Care Enrollment

<!--[if !supportLists]-->o        Top 25 Managed Care Organizations, Ranked by Total Health Plan Enrollment* (as of December 2006)<!--[endif]-->

Manufacturer Collaboration/Partnerships

• Pharma Tackles Patient Adherence, Managed Care, September 2006
• Reframing the Pharmaceutical Manufacturer/Health Plan Relationship in Managed Care, Managed Care, February 2002
• Pharmaceutical Industry And Payer Partnerships - Program Overview, Legal Updates, and Panel Discussion (special supplement to Managed Care), April 2001

Utilization Management

• PA NO MORE? Or are payers looking at other ways to manage high-cost specialty therapies? by Lola Butcher (Biotechnology Healthcare, August 2007)

 

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