How can a switch from the medical to the pharmacy benefit affect immunoglobulin access?

A switch can change who supplies immunoglobulin, who handles the drug claim and where the medication is delivered. These changes can affect patient cost sharing and clinic logistics.

The benefit change can shift patient costs

AMCP's report describes payers using specialty channel programs to move IVIG coverage from the medical benefit to the pharmacy benefit. The report says this can shift more cost to patients, depending on their copayments or coinsurance.

The change may also reflect a plan sponsor's effort to carve out infusion products. AMCP reports growing interest among self-insured employers and plan sponsors in carving out products such as IVIG, with pharmacy benefit managers offering specialty pharmacy programs staffed by pharmacists and clinicians. The stated aims include proper administration, adherence and fewer hospitalizations related to disease exacerbations.

The pharmacy may handle the drug claim

With white bagging, a specialty pharmacy ships patient-specific medication to the provider's office. With brown bagging, it ships the medication to the patient, who brings it to the office for administration, according to the Infusion Providers Alliance.

In testimony to Oregon lawmakers, an Oregon Society of Health System Pharmacists legislative co-chair described how these arrangements handle payment. The provider does not purchase the drug or seek reimbursement for it. Instead, the specialty pharmacy adjudicates the drug claim and collects patient cost sharing before treatment, while the provider is paid for administration. That changes the clinic's role in obtaining and billing for the medication.

Supply and scheduling can follow a different path

An OHSU specialty pharmacy director described an OHSU rheumatology patient restarting IVIG after transferring care. The insurer required the patient to obtain the drug from an external pharmacy, which shipped it directly to the patient for administration by a home nurse.

A published account from an academic medical center says medication bagging costs payers less because the drug is billed through the pharmacy benefit, which tends to have a lower charge structure than the medical benefit. The same account says outside specialty pharmacy shipments can leave drug integrity uncertain for the receiving site, and shipment delays can postpone therapy.

Build the channel into practice planning

For practice owners, a benefit change can alter the handoff among the plan, specialty pharmacy, clinic and patient. Before scheduling a treatment, staff can confirm which pharmacy supplies the drug, where it will be delivered, who processes the drug claim and how the administration service is paid. Those details help the practice plan its workflow around the required channel.

For decisions about an individual patient's treatment setting, the patient should discuss the plan with their prescribing doctor.

This page is general education only. It is not medical advice. Talk with your own doctor about your health.

Immunologists.com is a business directory and education site. It does not give medical advice, rank or rate care, or refer patients. Listings come from public registry data and are not endorsements.