1 / 23

Drug Formulary Management in MCOs – View from the Private Sector

Drug Formulary Management in MCOs – View from the Private Sector. DoD PE and Drug Benefit Management 12 January 2005 Frederic R. Curtiss, PhD, RPh, CEBS Editor-in-Chief Journal of Managed Care Pharmacy Clinical Director - PharmaCare-Texas. Objectives. Define the 80/4 rule

garrett-rhodes
Télécharger la présentation

Drug Formulary Management in MCOs – View from the Private Sector

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Drug Formulary Management in MCOs – View from the Private Sector DoD PE and Drug Benefit Management 12 January 2005 Frederic R. Curtiss, PhD, RPh, CEBS Editor-in-Chief Journal of Managed Care Pharmacy Clinical Director - PharmaCare-Texas

  2. Objectives • Define the 80/4 rule • Describe the difference between a low net-cost drug formulary and a high net-cost drug formulary • Compare and contrast the relative value of the following in drug benefit management: • Low net-cost drug formulary • Benefit design • T-MAC

  3. Top 12 Drugs by Expenditureaverage charge per 30-day supply – 3 months end 11.30.04

  4. ratio of top 12 and top 100 drugsto total Rx benefit expenditures

  5. generic drug pipeline

  6. XYZ Corp.Average Copay % for Single-Source Brand Drugs

  7. Optimum Drug Benefit Design • 3-tier copay design • tier-1 copay: $ 5 (generic drugs) • tier-2 copay: $ 20 or 20% (formulary brand drugs) • tier-3 copay: $ 35 or 35% (non-formulary brand drugs) • 30-day maximum supply • 90-day supply of maintenance drugs at mail for greater of 2X dollar copays or 20% for tier-2 drugs and 35% for tier-3 drugs

  8. Effect of $100 and $200 Annual Rx Deductibles on Beneficiary-Users

  9. Meta-analysis of Oral Triptan Therapy for Migraine: Number Needed to Treat and Relative Cost to Achieve Relief Within 2 Hours Adelman JU, Belsey J. JMCP 2003 9:(1)45-52.

  10. Methods • Randomized, double-blind, placebo controlled trials • Single-dose triptan treatment with no rescue or repeated dose for 2 hours • Headache assessed on 4-point pain scale Adelman AU, et al. JMCP 2003; 9(1):45-52

  11. Triptan Efficacy Data Adelman AU, et al. JMCP 2003; 9(1):45-52

  12. Drug Interactions *Decrease Maxalt dose by 50% if on propranolol

  13. Medical Necessity or Trojan Horse? • Early Warning Signs and Symptoms of……? • lack of close friends or confidants • exaggerated self-opinion • suspiciousness • difficulty in abstract thinking • difficulty performing functions at work or school • flat emotions • passivity to social activities and disinterest • preoccupation with religion or meditation • déjà vu

  14. HyperlipidemiaNew Developments – evidence and pseudo-evidence • pravastatin reduced absolute risk of stroke by 0.8% and relative risk by 19% • 9,014 patients with Hx of MI or unstable angina followed for six years on pravastatin • 3.7% incidence of stroke v. 4.5% for placebo [NEJM 2000;Aug 3:317-26] • no effect on hemorrhagic stroke (only ischemic stroke) • $752,813 in (discounted) Pravachol drug cost to prevent one (1) non-fatal stroke • subsequent letters in NEJM [2000;Dec 21:1894-5] critical of study and article: • erroneous literature citations (e.g., West of Scotland – no reduction in rate of stroke) • statistical significance 0.05 on univariate analysis but 0.10 on multivariate analysis • lack of practical significance – 750 patients for one year to prevent one (nonfatal) stroke • failure to measure left ventricular function (LVF) as a risk factor • 18% of patients with CHD reached NCEP goal with anti-lipid therapy • where: study of 4,888 patients in a 350,000-member group-model HMO • 85% of patients with dyslipidemia treated with drug therapy • 38% of all patients reached NCEP goal • 18% of patients with CHD reached NCEP goal • culprits included intolerability to drug therapy, poor compliance and low drug dosages • Arch Intern Med 2000;160:459-67 • 97% of patients on low-dose (5-10mg) simvastatin converted to 10-20mg lovastatin • prospective study of 96 VA patients (61% with CHD) [Am J Health-Syst Pharm 2000;Sept 15] • patients not meeting LDL goal decreased from 52% (initial assessment) to 26% by second follow-up

  15. heartburn drug therapy Your Health Plan – 3 months end 11.30.04

  16. cholesterol-lowering drug therapy Your Health Plan – 3 months end 11.30.04

  17. cholesterol drug therapy3-tier drug plan

  18. cholesterol drug therapy$3/$20 plan

  19. heartburn drug therapy – therapeutic MACYour Health Plan - 3 months end 11.30.04 ($1.00 per day)

  20. COX-2/NSAID drug therapy: t-MACYour Health Plan - 3 months end 11.30.04 ($1.00 per day)

  21. hypercholesterolemia – therapeutic MACYour Health Plan 3 months end 11.30.04

  22. Review • Define the 80/4 rule • Describe the difference between a low net-cost drug formulary and a high net-cost drug formulary • Compare and contract the relative value of the following in drug benefit management: • Low net-cost drug formulary • Benefit design • T-MAC • What about disease management? • http://www.cbo.gov/ftpdocs/59xx/doc5909/10-13-DiseaseMngmnt.pdf

  23. Path to the Answer “This crazy lady needs to be punished.”

More Related