10/01/2009
POSITION ON STATE MEDICAID DRUG REIMBURSEMENT FOR BIOLOGICS
Recognizing the unique nature of biologics, MedImmune supports appropriate Medicaid reimbursement for biologics, including for care management services, to help ensure patients’ safe and effective use with these therapies.
Background
Most state Medicaid drug reimbursement formulas are “one size fits all” in that they do not distinguish between biologics and chemical-based pharmaceuticals, nor do they fully recognize the extensive level of support services needed for patients using biologics. It is critical that states change this approach and recognize the unique nature of biologics and implement separate reimbursement mechanisms for biologics, since any reduction in reimbursement for biologics under existing Medicaid reimbursement formulas may result in inadequate compensation for patient support services and thereby reduce patient access to biologics; decrease the number of participating specialty distributor providers; and ultimately, increase costs to the state due to patients’ failure to obtain all necessary prescribed therapies.
Biotechnology drugs, or biologics, offer new hope to patients by providing novel therapies to treat unmet medical needs and debilitating health conditions. Biologics are complex medicines that are markedly different than most traditional chemistry-based pharmaceutical drugs in how they are developed, manufactured, stored, delivered and administered.
- Biologics consist of large, protein-based molecules that are manufactured using living organisms, and as such, are far more complex to produce than small molecule products.
- Biologics are generally prescribed by physician specialists (e.g., oncologists, rheumatologists, dermatologists, pediatricians, etc.) and historically target hard-to-treat diseases for which there are few, if any, effective therapeutic or preventive options.
- Biologics are most commonly administered via injection or infusion.
- Biologics are usually shipped by specialty distributors directly to the healthcare provider to ensure the proper storage and handling (referred to as maintaining proper “cold chain”) from manufacturer to the end user.
- Biologics require a variety of critical support services (often provided by the specialty distributors) to help ensure successful patient outcomes, including:
- coordination of the drug’s delivery with scheduled patients’ visits to the provider;
- patient tracking services (requiring compilation of data from several sources) to ensure patients receive follow-up doses as prescribed;
- patient counseling and compliance education; and
- educational services and product information for healthcare providers and office staff.
Policy Position Current on October 1, 2009
Download POSITION ON STATE MEDICAID DRUG REIMBURSEMENT FOR BIOLOGICS (PDF, 30.4KB)
