Defining the great debate.

Abstract

Treatment guidelines offer a credible approach to MCO management of specialty pharmaceuticals by basing decisions on the best available scientific evidence. Drawbacks to using guidelines include lack of available evidence, bias on the part of the expert team, a lack of currency, and difficulties in implementation. Treatment guidelines can and often do serve, along with product labeling, as the basis for reimbursement and usage rules as specified in MCO medical policies. The relationship between provider-oriented guidelines and payment criteria varies by payer, with implications for care quality, cost, and access. Increased awareness of the advantages and disadvantages of using treatment guidelines to shape prescribing policies for specialty pharmaceuticals may lead to worthwhile non-product-specific discussions within MCOs about sources and methods used in medical policy development.