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Tips for Reading Your Prescription Drug Formulary

July 07, 2014 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings Source: Navitus Clinical Blog, 6.24.14

The term “formulary” is often used in health insurance materials, but many people may not know what it means. In truth, a formulary is simply an elaborate word for a list of preferred drugs covered by your plan.

Perhaps even fewer people understand how to read a formulary. We have provided some questions and answers below that will help you interpret your formulary.

Which drugs are covered?
The drugs listed on your formulary are the ones covered by your plan. Your formulary is also available to your physician. It is always good practice for you to keep track of your formulary so that you are aware of which drugs have the lowest copay.

How do I know what my copay is? 
The copay level for each medication is shown on your formulary. Please note that your formulary does not show the dollar amount you pay for each medication.

Tiering 101
You may have heard the term “tiers” in relation to formularies. Here is how they work. The lower tiers (e.g., Tier 1) include the preferred drugs – and those preferred drugs typically have lower copays. To keep your expenses down, you should try to take drugs that are on lower, preferred tiers and avoid drugs in the higher, non-preferred or non-formulary tiers.

Typically, the format of a formulary includes three tiers of coverage.

  • Tier 1 – includes mostly generic drugs
  • Tier 2 – typically formulary brand name drugs
  • Tier 3 – in general, non-formulary brand name drugs

Why aren’t certain drugs added to the formulary?
The formulary is a list of preferred drugs. They were selected because they are safe, effective, and have better value compared to other more expensive drugs. Additions, exclusions and coverage changes to your formulary are made at the discretion of a committee of prescribers and pharmacists. This committee first reviews drugs based on therapeutic value, effectiveness and side effects. Then the committee determines which drugs are comparable and lastly considers cost. The goal is to provide the best quality medications at the best value. Ongoing review of new and existing prescription drugs ensures the formulary is up-to-date, and meets patient health care needs.

Some drugs on the formulary have PA, ST or QL listed after them.  What does that mean?

  • PA means that drug requires a Prior Authorization to be covered. A PA might be required for those drugs that require special consideration, such as needing specialist review or an approved test.
  • ST means the drug is subject to step therapy. This means the drug will be covered only after you have tried other drugs and they have failed. You may need to first try a safe and more cost-effective drug before moving to a more costly treatment.
  • QL means the drug is subject to quantity limits.

What is the difference between generic drugs and brand-name drugs?
A generic drug is a drug that is the same as a brand-name drug in dosage, safety and strength. It is also the same in how it is taken, how it works in the body, quality, performance and intended use.

The Food and Drug Administration reviews all generic drugs. They use the same strict criteria used for approval of brand-name medications, requiring generic drugs to have the same quality and performance as brand-name drugs.

Typically, generic drugs are less expensive than their brand counterparts. They can save you money by reducing copays or, in the case of over-the-counter drugs, reducing out-of-pocket expense at the cash register.

We hope the tips provided above will help you read and understand your formulary. Sometimes, just knowing a few bits of information can take you a long way in realizing the full potential of your pharmacy benefits.

Should I Vaccinate my Child?

June 19, 2014 By: Chelsea Liebowitz Category: HealthCare, Medicine Advice, Medtipster, Prescription Savings Source: Chelsea Liebowitz, Intern, Pharm.D., Medtipster Mentorship Program – 6.18.14

All over Facebook and the news are articles regarding vaccinations. “Should I vaccinate my kid? Is it safe? Doesn’t it cause autism? Nobody really gets those diseases anymore anyways.” Comments on the articles posted on Facebook range from criticizing those who don’t vaccinate to hating on those who do. So who is right? To understand more about vaccines and why we need them, we first have to understand the harm the diseases caused before the vaccine was present. In this blog, we will discuss three different diseases: small pox, polio, and measles.

SMALL POX is an infectious disease which is characterized by a maculopapular rash, which later can turn into raised fluid-filled blisters. Long term complications include scars, commonly on the face, and less commonly, blindness and limb deformities.1

Epidemics in Boston (1721) and London (1751) resulted in 844 deaths and 3,358 deaths respectively.2 In 1882, rumors started saying that small pox was not spread by contagion but by filth.2 This idea spread due to lack of modern science techniques, leading to neglect of vaccinations. Eleven years later, in 1893, another smallpox outbreak occurred. This ended with 140 people contracting the virus, with 20 deaths.2 While the numbers are significantly lower than before, this is because another 13,000 were vaccinated to help stop the further spreading of the disease.2 It wasn’t until 1980 that the virus was finally declared eradicated.2

POLIO, short for poliomyelitis, is an infectious viral disease that affects the central nervous system. This disease can then cause temporary or even permanent paralysis, and in some cases, death.1

The first US polio epidemic occurred in 1894.2 It resulted in 18 deaths and 132 cases of permanent paralysis.2 Almost sixty years later, in 1952, a shocking 57,628 cases of polio were reported, with more than 21,000 cases including paralysis.2

In 1955, a polio vaccine clinical trial was shown to be 80-90% effective against paralytic polio.2 Once the vaccine was being distributed to the general population, unfortunately there were strange cases of vaccinated patients still contracting the virus once they had been vaccinated. The strange part was that instead of the paralysis starting in the legs, like normal, the paralysis started in the vaccinated arm.2 However, as more cases were reported, it was shown that the production of the vaccine was the issue, not the vaccine itself.2  A subcommittee, which included researchers and public health officials, made several changes to the production methods to ensure safety of the patient.2 Some of the changes include testing larger samples of each vaccine lot, using filters that would remove clumps of  virus that might resist chemical inactivation, and also to test the vaccine once it was bottled.2 Despite these changes some locations declined to participate due to the “dangerous nature” of the vaccine.2

In 1985, the World Health Organization set to eradicate polio in the Americas by 1990.2 In 1988, the World Health Assembly voted to launch a global polio eradication (hopefully by 2000) due to polio being endemic in 125 countries.2 The World Health Organization stepping in was a big step for polio eradication. Between 1988 and 2013, they successfully reduced the rates by 99%.2 In 1994, polio was said to be eradicated in the Americas.2

Good news, right? Unfortunately, between 2013 and 2014, there has been an 86% INCREASE in wild polio virus (WPV). Eight countries have had outbreaks of polio, five of which were previously polio-free!4 What caused the increase in WPV cases? Experts believe the outbreak(s) was triggered by local leaders in North and South Waziristan having a ban on polio vaccinations.4 The ban prevented over 350,000 children from getting vaccinated. The unvaccinated children in these locations then spread the WPV to Pakistan, and from there it spread to Afghanistan and Syria.4 Once again, lack of vaccinations led to increases in infectious disease cases.

MEASLES is a respiratory disease and is highly contagious. Symptoms include fever, runny nose, cough and a rash all over the body. An ear infection or pneumonia may also be present.1

In 1861, there were 21,676 reported cases and 551 deaths in the Union Army alone during the Civil War.2 Two thirds of the 660,000 total soldier deaths were caused by uncontrolled infectious disease.2 TWO THIRDS died not from fighting, but from some type of infectious disease, including measles. In 1951, a massive epidemic hits Greenland. Of the 4,262 population, all but five contracted the disease.2 The attack rate was 99.9%.2 Finally, in 1958, the measles vaccine started testing. It was successful in creating measles antibodies; however a rash was present as a side effect.2 This told the researchers the virus needed to be weakened more before giving to patients. In 1962, a “dead strain” vaccine was tried, however it was ineffective.2 The virus needs to be alive but weakened in order for the vaccine to be effective.  In 1963, the measles vaccine was licensed in the United States, and over the next 12 years, nearly 19 million doses were administered. In 1978, the CDC targeted to eliminate measles from the United States by 1982.2 Unfortunately, the goal was not met, but by 1981, the number of reported cases went down 80% compared to the previous year. The CDC also noted that only 778 cases were reported in the first 14 weeks of 1981, while 3,897 cases had been reported during the same first 14 weeks of 1980.2 This is a huge improvement, even if the goal of completely eradicating the disease was not met.

Between 1989 and 1991, 55,000 Americans contracted measles, killing 123.2 In Philadelphia, 1,500 children fell ill and nine (all of which were not vaccinated) died.2 Like with polio and smallpox, it was shown that outbreaks were centered in areas where immunization levels are low.2 It took another 9 years (2000) until endemic measles was in fact eliminated from the united States.

So what do these three infectious diseases have in common? Even with the science to get rid of the disease, citizens who refused the vaccine are the starting point of epidemics that started after the vaccine came out. Repeatedly, when the technology was present and available, epidemics still happened. Polio was said to be eradicated in 1994. Today, polio is making a comeback across the globe due to unvaccinated children. How much longer until it reaches the United States? In 2000, endemic measles was eliminated. But through May 23 of this year, there is the highest year-to-date total number of measles cases since 1994.5 The CDC determined that most of the virus transmission is being done through individuals who travel outside the country, bring it back onto US soil, and infect those who are unvaccinated.5 This continues the spread, and due to the contagious nature, the disease can be spread very rapidly.

                Currently, small pox is still under control. But if people are refusing polio and measles vaccines, who says they won’t refuse the small pox vaccine? History tends to repeat itself. California has seen a rise in whooping cough (or pertussis), another disease that can easily be vaccinated for, with the number of infection nearly tripling since the previous year due to….low vaccination rates.3

                All three of these diseases are successfully preventable with simple vaccinations. Not only does vaccinating your child help protect them from potentially deadly diseases, but it can help stop the spread of the disease to other people. Many years of research and testing has been put into both the theory and practice of vaccines. While there are risks of side effects, the doctors giving the vaccines believe the benefits of the vaccine greatly outweigh the risks of the vaccine. Trust them! If you can’t trust your doctor, the professional who has spent years of his life in college and put himself into debt to get this career,  to give you the best care (which includes vaccinations), who can you trust?

                A common (and popular) myth associated with vaccines that I would like to quickly address is the myth that vaccines cause autism. THIS IS FALSE! From the CDC, “The 1998 study which raised concerns about a possible link between measles-mumps-rubella (MMR) vaccine and autism was later found to be seriously flawed, and the paper has been retracted by the journal that published it…There is no evidence of a link between MMR vaccine and autism or autistic disorders.”6

Just like in 1882, anti-vaccine ideas came about by saying smallpox was spread by filth, not contagion. The idea quickly spread, and in 1893, another smallpox outbreak occurred. Learn from this! The study claiming vaccines cause autism is FLAWED and has been RETRACTED by the journal that published it. The study is no longer valid.

Do you have more myths you are worried about? Check out this site to learn more about myths and the truth behind them all.



1Center for Disease Control and Prevention (CDC). (2014). Retrieved from

2The College of Physicians of Philadelphia. (2014). Diseases and Vaccines Timeline. The History of Vaccines. Retrieved from

3Kearney, L. (April 24, 2014). California City Sees Spike in Whooping Cough Cases. Reuters Health Information. Retrieved from 

4Kelly, J. C. (June 02, 2014). Uptick in Worldwide Polio Cases in 2013 Continues Into 2014. Medscape Medical News. Retrieved from  

5Lowes, R. (May 29, 2014). Measles Vaccine Refusal Helps Make 2014 a Record Year. Medscape Medical News. Retrieved from

6World Health Organization. (April 2013). What are some of the myths- and facts- about vaccination? Retrieved from

U.S. Spending on Prescription Drugs Rose 3.2% in 2013

April 16, 2014 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News Source: IMS Institute for Healthcare Informatics, Chad Terhune – LA Times, April 16, 2014

A historic slowdown in U.S. healthcare spending in recent years may be drawing to a close.

An industry report published Tuesday and healthcare experts point to a steady rise in medical care being sought by consumers seeing specialists, getting more prescriptions filled and visiting the hospital. Other factors such as millions of newly insured Americans seeking treatment for the first time and higher prices from healthcare consolidation could also help drive up costs.

Experts aren’t predicting an immediate return to double-digit increases in medical spending. But the emerging trend underscores how difficult it will be for policymakers, employers and health plans to control healthcare costs going forward.

“2013 was a rebound year for healthcare,” said Murray Aitken, executive director of the IMS Institute for Healthcare Informatics, an industry research firm that released Tuesday’s report. “We saw healthcare usage overall up for the first time in three years. We think that is reflective of a strong economy, more patients with insurance and also some pent-up demand for services that may have been delayed or deferred since the economic downturn.”

David Gruber, director of healthcare research at Alvarez & Marsal, said he’s expecting a similar trend of higher demand coupled with consolidation among hospitals and large physician groups pushing up prices. He said the demand for services is being driven by an influx of Obamacare enrollees, aging baby boomers and people with chronic conditions who can no longer delay care.

“At some point you can’t defer anymore,” Gruber said. Health spending “isn’t going up by double digits, but it could spike to 6% or 7%.”

There are other forces at play that could serve as an effective counterweight and bear watching. The growing use of narrow provider networks by employers and health insurance companies and a shift away from conventional fee-for-service reimbursement for medical providers can be potent cost-containment tools, Gruber said.

On Monday, the Congressional Budget Office cited the prevalence of narrow networks as one reason premiums for Obamacare coverage in government-run exchanges will be lower in the next few years than previously expected.

David Axene, a fellow at the Society of Actuaries, estimates that rates for individual consumers under the health law may rise, on average, 6% to 8.5% next year. He cautions that rates will vary across the country, and some health insurers such as industry giant WellPoint Inc. have already warned about double-digit rate hikes in some markets.

“Many exchange health plans got better discounts than anticipated from providers, but there is really a strong pushback now from hospitals and physicians who are concerned about having enough money to cover their costs,” said Axene, an actuary in Murrieta. “I hope we can stay south of double digits, but there’s no guarantee we will.”

From 2009 to 2012, U.S. healthcare spending grew annually at less than 4%, according to federal data. That’s been the lowest rate of growth in half a century, and has sparked considerable debate about the underlying reasons.

Many health economists and industry officials have attributed the slowdown primarily to lingering effects of the Great Recession, when millions of Americans cut back on medical care. But the Obama administration and other experts have pointed to fundamental changes in healthcare reimbursement and the delivery of care spurred by the Affordable Care Act.

The IMS Health report found that total U.S. spending on pharmaceutical drugs grew 3.2% last year to $329.2 billion. That came after a 1% drop in 2012 — the first decline since IMS began tracking the data in 1957.

Patent protections expiring on major drugs and cheaper generic substitutes flooding the market helped drive that previous decrease. Aitken said patent expirations had less impact last year and there was greater use of healthcare in general.

IMS Health also found that the number of physician office visits, hospitalizations and prescriptions filled all rose last year.

At the doctor’s office, visits to primary care physicians fell less than 1%, but trips to specialists jumped 5%. The number of hospital visits also grew last year, primarily among commercially insured patients who received outpatient treatment.

Any upswing in medical costs could further squeeze workers. Their health insurance premiums keep taking a bigger bite of their paychecks, as employers shift more healthcare costs to employees.

There was some good news for consumers. The IMS report found that 57% of all retail prescriptions filled last year cost consumers $5 or less. But patients often bear a growing share of the cost for high-priced specialty medications for cancer, rheumatoid arthritis and other chronic conditions.

Combatting Adverse Drug Events

February 24, 2014 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News Source: Navitus Blogs – Clinical, February 18, 2014

Adverse drug events (ADEs) can happen to anyone taking medication. An ADE is defined as any injury or harm caused by a drug in any circumstance. According to the Centers for Disease Control and Prevention (CDC), 82% of adults in the U.S. currently take at least one medication on a consistent basis, and 29% take more than five medications. No one is immune to ADEs; they can occur when using over-the-counter (OTC) or prescription medications (Rx). The bottom line is that it’s important to be able to prevent, recognize, and report ADEs.

When ADEs Occur
ADEs take place in many different situations. For example, individuals taking OTC medications may not realize the impact these drugs can have on their bodies when combined with their current prescription drug regimens. Just like prescription medications, OTC medications can cause side effects and can interact with other medications—which could eventually lead to ADEs. The best way for members to recognize the potential harm these medications can cause is to inform their prescribers and pharmacists of all the OTC medications taken on a regular basis.

Sometimes, taking one medication alone can cause an ADE due merely to the medication’s side effects. Other times, additional causes such as incorrect medication, missed dose, wrong technique, duplicate therapy or duplicate ingredients, and drug-drug interaction can precipitate an ADE. According to the CDC, 700,000 emergency department visits and 120,000 hospitalizations occur annually due to ADEs, which account for $3.5 billion in medical costs.

For more information regarding ADEs, Please visit the CDC website,


Vaccines: Remind members to get a flu shot!

October 31, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings Source: Navitus Clinical Blog, 10.23.13

It’s that time of year again! You may want to encourage your members to get their flu shots for the upcoming season. It’s important to remember that our immune system loses strength as we age. Influenza is a serious disease that can lead to hospitalization and sometimes even death. Every flu season is different, and influenza infection can affect people differently. Even healthy people can get very sick from the flu and spread it to others.

The Centers for Disease Control and Prevention (CDC) recommends that everyone over the age of 6 months (with a few exceptions) receives an immunization. Those over the age of 50 are particularly susceptible to complications from the flu, especially residents of nursing homes or other care facilities.

In addition to being a wise investment for good health, preventive measures against the flu also result in reduced health care costs. According to the CDC, more than 64 percent of Americans did not receive flu immunizations in 2012, even though the vaccine proved to be 62 percent effective. This means that persons who received the vaccination were 62 percent less likely to develop the flu than those who did not. During an average flu season, the CDC estimates that the flu complications cost employers $10.4 billion in hospitalization and outpatient visits.

If you already have a Vaccination Program in place, remind members about its availability. If you don’t offer this program to your members, please consider the following:

Vaccinations are available at retail pharmacies, thus saving clients and their members the cost of clinic or physician fees. Not only is this delivery channel more cost-effective, but many members find it more convenient as well.

Three different vaccination offerings are typically available:

  1.   Influenza only
  2.   Influenza, pneumonia, and tetanus/pertussis
  3.   All vaccines, including shingles

Two of the most commonly offered vaccines are for influenza and pneumonia. Clients may also offer vaccines for tetanus, hepatitis, shingles, measles, mumps, HPV (human papillomavirus), pertussis, varicella and meningitis. Vaccinations typically cost between $25 and $35, plus the pharmacy dispensing fee.

Because vaccinations are considered a preventative service under the Patient Protection and Affordable Care Act (PPACA), vaccines must be offered to members at a $0 copay.

Pharmacy Trends for 2013 and Beyond

May 29, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings

As pharmacy trends shift and costs for plan sponsors increase, we continue to maintain a panoramic view of the industry to control medication spend for our clients. By keeping plan sponsors informed of these shifts and our strategies for handling them, plan sponsors are empowered to make informed choices about their pharmacy benefit plans. In the spirit of our transparent business approach, following are some key trends we foresee occurring in this marketplace.

Generics Plateau

In 2012, new generics entering the market reached record highs, with more than 80% market share as two major brand products (Lipitor and Plavix) lost their patents. The product with the fastest growth in 2012 was atorvastatin  – the generic version of Lipitor. The medications were considered blockbuster agents, with more than $1 billion in annual sales before turning generic.

While sales of generics grew, sales of brands decreased. Because of the influx of generic products, 2012 was a marquee year. As such, we expect fewer generics exclusivity periods in coming years, and generics are expected to reach a ceiling where they can no longer surpass their current market saturation.

Growth & Trend by Therapy Class

Therapy classes with the most growth in 2012, based on total scripts dispensed, included:

• Anti-depressants • Seizure disorders • Proton Pump Inhibitors

The top five therapy classes, which accounted for one-third of plan sponsor drug spend, included:

• Oncologics  (used to treat cancer) • Respiratory agents (used to treat asthma and Chronic   Obstructive Pulmonary Disease (COPD)) • Antidiabetics (used to lower elevated blood sugars) • Lipid regulators (used to lower high cholesterol or related   disorders) • Antipsychotics (used to treat schizophrenia and related   disorders)

Trends in Specialty

Less than one percent of the U.S. population uses specialty medications, but these products account for 25% of all pharmacy spend. As you are aware, the staggering costs in this pharmacy channel are not new. The good news is that we hope to see increased competition soon, with 38 specialty products expected to have patent expirations through 2017, and new legislation that will promote competition in this therapeutic space.

At the same time, the FDA has approved many more drugs in recent years that treat oncology and orphan diseases. Orphan drugs are used in treating very rare diseases, known as orphan diseases. Because of the niche market on these products, the cost to produce and sell them is very high. For instance, five of the most recently approved orphan drugs will cost at least $150,000 per patient per year. Costs for these products will only continue to rise, since drug makers and biotechnology companies for these products currently have no competition.

Are You Adhering to Your Prescription Drug Regimen?

March 28, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings

Adhering to medication means taking the medication correctly, as instructed by a health care professional. This includes filling and refilling the prescription, taking it regularly, and continuing to take it for as long as prescribed. While this may seem simple, the World Health Organization has reported an average medication adherence rate of only 50 percent for people with chronic illnesses in developed countries. So, why is only half of the population taking their medicines as prescribed? Moreover, why is it important to adhere to your medication regimen anyway? Read on to find out why it’s important and how you can improve your adherence.

Why Adherence Matters?

Simply put, it can improve your overall quality of life. Evidence suggests that for many chronic illnesses, higher medication adherence reduces hospital visits. Fewer visits to the hospital mean lower medical costs as well.

Adherence to medication may be ‘easier said than done’ for many people. There are a variety of barriers that may make it difficult for patients to follow their medication therapy. Here are a few of those barriers and suggestions for how to get around them.


Often times, patients just cannot afford their medications. Perhaps there are alternative drugs available that do not cost as much. Talk with your prescriber or pharmacist. They may be able to help you find a more affordable drug.

You can also visit the Medtipster website,, to determine the cost of a prescription. The tool can help you compare the price on related drug products.

Side Effects

Your medicine may trigger unpleasant side effects, causing you to stop taking it. Talk to your doctor about these side effects. They may be able to switch you to a different medicine to reduce the side effects. They may also have suggestions for minimizing the side effects. Your doctor has your best interest in mind and is a knowledgeable resource to help improve your quality of life.

Feeling Better

There are five pills left, but you started to feel better and decided to stop taking your medicine. Before you stop, talk to your prescriber. Stopping early may cause more health problems. For instance, if a patient has a bacterial infection and stops taking his or her medicine early, some bacteria may still be alive. These bacteria could start a whole new strain of resistant germs. (U.S. Food and Drug Administration, 2009). Even though you may feel better, try to continue to take your medicine(s).


Make taking your medicine a part of your daily routine. Once you are used to taking your medicines regularly, it will not seem like a burden on your lifestyle. Buying a pill minder dispenser may help; it’s an easy daily reminder to take your medicine. Write down a schedule of when to take your medicines or add it to the calendar on your electronic device.

Health Care Beliefs and Attitudes

Some patients hold certain beliefs or attitudes that stop them from being adherent to their medication regimen. For example, a patient may believe that taking a medication as prescribed will not lead to a predicted outcome or that a particular disease state is not significant or will not lead to severe untoward outcomes. Talk with your prescriber about your beliefs. He or she may have more information about your illness and medicine than you know.  Your prescriber can tell you why it is in your best interest to adhere to taking your medicine(s).

Adhering to your medicine can improve your overall quality of life, so take care to adhere to your prescribed medication regimen. For a better result, you will be glad you attended to your health.

5 Tips to Managing Your Insurance Coverage

March 26, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings

Don’t use providers that aren’t in your network. Most plans have lowered how much they will pay for doctors or facilities not in your network, while some won’t pay for out-of-network providers at all.

Review how prescriptions are reimbursed under your coverage. Many plans are now offering reimbursement based on a percentage of the retail cost of a drug, which can add up quickly. If you pay a percentage instead of a co-pay, compare prices at different pharmacies.

Prepare for a doctor visit ahead of time if you anticipate a prescription, diagnosis or treatment plan. You should have your benefits summary with you as well as your drug formulary to know how much you’ll pay for a prescription before you leave the office. You can also pull up prices at local facilities on your tablet or phone at to discuss choices with your doctor.

Read your benefits summary carefully to know what’s in your plan, and what isn’t.

Shop for the lowest priced facility for diagnostic tests. Hospital-based services are often priced higher than independent facilities.


Specialty Drug Trend of 18.4% Dwarfs Traditional Drug Trend of -1.5%

March 11, 2013 By: Nadia Category: HealthCare, Medtipster, Prescription News, Prescription Savings Source: Drug Channels, 3/6/2013

Express Scripts just released the latest iteration of its long-running Drug Trend Report. This year’s report includes both Express Scripts and legacy-Medco covered lives, so it’s the most comprehensive look at pricing and utilization.

Study findings

  • Specialty drug trend of 18.4% dominated traditional drug trend of -1.5%.
  • Drug trend for traditional drugs fell to a record-low -1.5%, due largely to the growing substitution of less-expensive generic drugs.
    • Utilization increased by 0.6%, but costs decreased by 2.2%.
  • Drug trend for specialty drugs was 18.4%, consistent with its high growth rate over the past six years.
    • Utilization decreased by 0.4%, while costs increased by 18.7%.
  • Specialty spending is concentrated in a few conditions. For traditional drugs, treatments for the top three conditions of diabetes, high blood cholesterol, and high blood pressure–accounted for 30% of total per-member, per year (PMPY) spend.
  • For specialty drugs, treatments for the top three conditions–inflammatory conditions, multiple sclerosis, and cancer–accounted for 58% of total PMPY spend.
  • Trend reflects two primary components
    • Change in Utilization (the total quantity of drugs obtained by plan members)–Utilization varies with changes in the number of plan members on drug therapy, the degree to which plan members are adherent to their drug therapy, and a change in the average number of days of treatment.
    • Change in Unit Costs–Unit costs vary with:
      • 1) the rate of inflation in brand-name drugs prices,
      • 2) shifts to different drug options within a therapeutic class,
      • 3) a shift in mix of therapeutic classes utilized by plan members, or
      • 4) the substitution of generic drugs for brand-name drugs.


The Importance Of Specialty Medication Management

January 03, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings Source: Navitus Clinical Journal, Vol. 9 – January 2013

Approximately one to five percent of the population uses specialty medications. Nonetheless, spending for specialty medications has increased between 15 and 20% for the last several years and is expected to represent up to 40% of an employer’s total medical spend by 2020. Controlling specialty medication cost is therefore a critical focus area for plan sponsors. With more and more specialty drugs coming down the pipeline, it will be increasingly important for plan sponsors to manage this area of their drug spend.

Managing this highly complex area involves coordination among multiple parties, including plan sponsor, pharmacy benefit manager (PBM), medical administrator, specialty pharmacy and the patient.

Benefits of Specialty Drug Control
Growth in specialty spending is expected to outpace non-specialty spending due to:

  1. High proportion of newly approved drugs in the specialty market
  2. Complex and expensive manufacturing processes
  3. Limited competition within specialty medication therapy classes

It is clear that plan sponsors can benefit from managing specialty costs. While specialty medications may represent a low percentage of the drugs purchased by the plan sponsor’s members, the cost of these medications represents much more than the actual percentage of medications purchased.

In addition to cost control, helping members adhere to their regimens with specialty medications is essential, as high adherence rates have been shown to reduce hospitalizations, promote better health outcomes and lower overall health care costs.

Ways to Manage Specialty Medications

1. Implement a Mandatory Program

We recommend that plan sponsors implement a SpecialtyRx program as mandatory for members with specialty needs. Specialty programs coordinate personalized support for patients impacted by chronic and complex diseases, such as rheumatoid arthritis, multiple sclerosis and cancer. Such diseases often require complicated medication regimens that include specialty medications. By mandating use of a specialty pharmacy vendor, plan sponsors reap the benefits of reduced drug discounts with specialty pharmacy partners (versus the typically higher retail pharmacy pricing), superior clinical oversight, and individual member case management

2. Incorporate a Split-Fill Program

A  Specialty Split-Fill Program reduces days’ supply to 15-day intervals for qualifying high-cost specialty medications that typically have high discontinuation rates within the first three months of therapy. This prevents unnecessary dispensing of two weeks of therapy, should therapy be discontinued within the first half of the first three months of a prescription. This program also allows specialty pharmacy to initiate earlier clinical interventions due to medication side effects that require dose modification or therapy discontinuation. According to the May 2012 issue of Managed Care, a health plan with about 500,000 members saved approximately $300,000 in its first year with a split-fill program.

3. Know your Specialty Costs Through Pharmacy & Medical

Plan sponsors should equip themselves with information about their specialty drug spend and track specialty costs not only through their PBM but through their medical vendor as well. Less than 20% of health plans and employers currently receive reporting from their PBMs or other health care vendors on medical specialty utilization. Given that plan sponsors identified specialty drug costs as one of their two most important outcomes for specialty management, and that 50% or more of the specialty spend resides on the medical side, this gap represents a critical area of opportunity.

4. Managed Specialty Programs relieve clients of the burden of managing their specialty populations and assume this responsibility through a comprehensive, patient-centric program that offers:

  • Built-in utilization management edits (e.g., prior authorization, step therapy) to ensure members use lower cost specialty products, where appropriate.
  • Continually negotiated lower discounts with specialty pharmacies.
  • Price increase protection built into rebate contracts for specialty drugs, where available, to account for price inflation; that is, when certain products increase in price, rebates for those products automatically increase as well.
  • Continual monitoring of new drugs entering the pipeline. Their Pharmacy & Therapeutics Committee will continue to monitor and evaluate specialty drugs, including any biosimilars being released. Biosimilars are products that are chemically similar to other products; very few have received FDA approval at this point. We expect biosimilars will be significantly less expensive than their specialty brand medication alternatives and will play a bigger role in controlling specialty trend in the future.

As an example, a plan sponsor’s employee has a very expensive specialty medication. This specialty drug utilization represents less than 2% of total utilization, but accounts for, on average, half of the plan sponosor’s drug spend. The previous discount for the drug was under 20% off the average wholesale price. After its transition to a managed specialty program, the discount for this drug rose to 47% off the average wholesale price, providing a savings of more than $140,000 in the first three quarters.

How to Begin to Control Specialty

If you do not currently use a mandatory program, talk to your provider today to implement the program. Plan sponsors can reap the benefits of  preferred pricing via a specialty pharmacy, and their members can benefit from the one-on-one specialized care from the case managers available through  specialty pharmacy vendors.

Be proactive and take control of this sector of your plan’s drug spend. By maintaining a tightly managed specialty program, not only will plan sponsors benefit from reduced costs, but their members will also benefit from improved overall health.

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