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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

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Drug Formulary Management in MCOs – View from the Private Sector

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  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.”

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