40+ Drugs to Be Dropped By Insurance

www.Medtipster.com Source: Elizabeth Davis – August 17, 2016

Americans, get ready for sticker shock at the pharmacy.

In 2017, the nation’s largest insurance companies will likely exclude up to 154 different drugs from coverage. If you’re taking one of these prescriptions, your co-pay is about to go way, way up.

Last year, popular drugs including Viagra and Qsymia were dropped by major insurance plans for 2016. The trend continues this year. Almost 50 popular brand-name and generic drugs will likely no longer be covered by one of the nation’s largest prescription insurance providers.

Who’s removing these drugs? Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million Americans, are once again removing drugs from their national preferred formularies. Other pharmacy benefit managers will likely announce similar restrictions in the coming weeks.

What are Express Scripts and Caremark?

Express Scripts and Caremark are companies that administer prescription drug benefits for many health insurance companies and Tricare. While you may have health insurance from Anthem, Aetna or another insurer, your pharmacy benefits are usually handled by these companies or their competitors. They create a formulary—a list of drugs they will cover—in conjunction with employers and health plans.

What does this change mean for you?

The newly excluded drugs fall into a couple major categories:

Several are brand-name drugs that may have a less expensive brand or generic alternative available.

Some drugs work in the same way as similar, cheaper drugs on the market, so only one is preferred by your insurance.

If your benefits are provided by Express Scripts or Caremark, you will pay the full cash price at the pharmacy for these excluded drugs in 2017.

If your coverage is changing, talk to your doctor to see if one of the covered alternatives might work for you. You may also be able to appeal the coverage with your insurance provider, with your doctor’s help.

Which drugs are affected?

Caremark in particular is making some major changes for 2016, which fall under three general categories: “hyperinflation” drugs (drugs that have had recent drastic price increases), new biosimilar alternatives, and stricter restrictions on expensive cancer and hepatitis C medications.

Hyperinflation. Caremark has identified some drugs that have had huge price increases, and excluded a selection that have similar alternatives in the same class of medications. One example is Alcortin A, which saw a 30-fold price hike over the past three years.

Biosimilars. You may have heard news over the past year or so about “biosimilars”—basically, generic medications for some specialty or biologic medications like insulin. (For more background on biosimilars, see our post here.)

Notably, Caremark will no longer cover Lantus, one of the most popular insulin brands.

Caremark is the first provider to restrict brand name drugs like Neupogen or Lantus that have (or will have) biosimilars available next year. They are suggesting Zarxio in place of Neupogen, and Basaglar in place of Lantus.

Express Scripts, in contrast, haven’t restricted coverage for either Lantus or Neupogen yet, but are maintaining that they plan to reassess based on upcoming product launches over the next year.

Expensive specialty medications. Caremark is also breaking ground by being the first provider to restrict coverage on brand name cancer treatments.

They are also restricting coverage for all of the new hepatitis C treatments, allowing only Sovaldi and Harvoni.

Express Scripts has similar—but not overlapping—restrictions, limiting coverage to only Viekira Pak and the newly approved Technivie, both from manufacturer Gilead.

How can I make sure I pick a plan that will cover my drug?

Both Express Scripts and Caremark have made some fairly big changes in coverage over the past few years, and the overlap on many of the excluded drugs is shrinking. If you’re trying to choose a new plan, or switch based on coverage of a particular drug, it’s always a good idea to review the latest formularies before deciding.

Below, you can find all of the new removals from both formularies in 2017. For a full list of all excluded drugs and covered alternatives, see the Express Scripts list here and the Caremark list here. If you’re not sure which company provides your pharmacy benefit, contact your insurance.

New Exclusions for 2017

Abilify (Caremark)

Abstral (Caremark)

Alcortin A (Caremark)

All non-BD pen needles and syringes (Caremark)

Aloquin (Caremark)

butalbital/acetaminophen/caffeine capsules (Caremark)

Carnitor (Caremark)

Carnitor SF (Caremark)

Colchicine (Express Scripts)

Crestor (Caremark)

Daklinza (Caremark)

Dexpak (Caremark)

Dutoprol (Caremark)

Effexor XR (Caremark)

Enablex (Caremark)

Evzio (Caremark)

Fioricet capsules (Caremark)

Gelnique (Caremark)

Gleevec (Caremark)

Helixate FS (Caremark)

Kineret (Express Scripts)

Klor-Con packets (Caremark)

Lantus (Caremark)

Millipred (Caremark)

Millipred DP (Caremark)

Neupogen (Caremark)

Nexium (Caremark)

Nilandron (Caremark)

Novacort (Caremark)

Olysio (Caremark)

Opsumit (Caremark)

Orencia (Express Scripts)

Pradaxa (Caremark)

Proventil HFA (Caremark)

Taltz (Express Scripts)

Tasigna (Caremark)

Technivie (Caremark)

Tobi (Caremark)

Toujeo (Caremark)

Venlafaxine ER (except tablet) (Caremark)

Ventolin HFA (Caremark)

Xenazine (Caremark)

Xtandi (Caremark)

Zebutal capsules (Caremark)

Zegerid (Caremark)

Zepatier (Caremark)

Zyclara (Express Scripts)

An important note about Medicare and individual plans:

These changes DO NOT apply to Medicare plans; if your Medicare benefit is managed by Express Scripts, you should check your coverage with your pharmacist or online through the Medicare.gov portal.

Some individual private insurance plans managed by Express Scripts or Caremark may also have different coverage. This means different drugs may be covered or excluded on your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.

6 Things You Need to Know About the Generic Drug Daraprim Price Hike

www.Medtipster.com Source: Dr. Sharon Orrange, MD MPH – 9.25.2015

Price increases on previously affordable medications is a familiar, though unwelcome, practice from the pharmaceutical industry. Recently though, aggressive price hikes have sparked outrage, even attracting the attention of presidential candidates Hillary Clinton and Bernie Sanders.

So where exactly do things stand with Daraprim (pyrimethamine), Seromycin (cycloserine), and the others?

1. Martin Shkreli, CEO of Turing Pharmaceuticals, has made headlines this week with a huge price hike on Daraprim.

2. Daraprim went from $13.50 to $750 per pill. After Turing acquired Daraprim from another pharmaceutical company last month, the price jumped 5,000%.

3. This isn’t the first time. Shkreli is the previous CEO of Retrophin, another biopharmaceutical company where the price of Thiola (tiopronin) was raised. Thiola is a medication used to treat cystinuria (cystine kidney stones), a rare genetic disorder commonly diagnosed in young children. The price for Thiola went from $1.50 per tablet to $30 per tablet—not quite as devastating as the Daraprim price change, but still a 2,000% increase.

4. Daraprim is one-of-a-kind in the US. Shkreli’s reasoning for this increase was the rare use of Daraprim—but it is currently the only US-approved medication for toxoplasmosis, leaving patients who need treatment with no other options. Toxoplasmosis is a parasitic disease that may not need treatment if you’re healthy, but can be harmful to anyone who has lowered immunity. Daraprim is commonly given to AIDS patients to prevent infection, though it is also used to treat toxoplasmosis infections in otherwise healthy people who show symptoms.

5. The price is going back down—but by how much? Now, Shkreli has said that Turing will lower the price of Daraprim “in response to the anger that was felt by people.” However, he has not stated what the new cost will be, only that it will still allow Turing to make a “very small profit.”

6. Other drug prices are also going back down. You may have also heard about Seromycin (cycloserine), a tuberculosis medication. Similar to Daraprim, cycloserine was acquired by a new pharmaceutical company, Rodelis. Rodelis then raised the price from about $17 to about $360 per pill—another increase of more than 2000%. Rodelis has now agreed to return cycloserine to its former non-profit owner, but cycloserine still won’t return to the old price. The new cost of cycloserine will be double the original—$1050 for 30 pills, rather than $500—but still far, far less than Rodelis’s $10,800 price tag.

Have you seen significant price increases for your prescriptions recently? Let us know, and watch for more information on high drug prices in the US.

More than Just Counting Pills

www.Medtipster.com Source: Chelsea Liebowitz, Intern, Pharm.D., Medtipster Mentorship Program – 5.20.15

As I walk up to the pharmacy counter at my local CVS to pick up my prescriptions, I notice a sign titled “Consultation,” and until recently, I did not know what the sign was for. I’d drop off my written prescription to the pharmacist under the “drop-off” sign and then pick it up at the “pick-up” sign; it was pretty simply really. I would briefly be asked if I had any questions for the pharmacist, asked to sign for my prescriptions, and given my prescriptions and sent on my merry way. I’ve been doing it for years and never thought to question it.

So what goes on under that “pharmacy consultation” sign?

A pharmacist is the only healthcare provider that is available to you at any given time. Twenty four hour pharmacies exist to allow accessibility at any time of day. They are also one of the most trusted professionals in the United States, ranking in the top 3 in terms of their honesty and ethical standards for the past 11 years.2

Pharmacists have at least 6 years of education starting with classes to understand the body and how a drug might affect a certain system, and ending with classes that include therapeutic applications of different drugs. They are trained to recognize and assess risk factors for disease, interpret data and recognize interactions of drugs and disease states. A pharmacist will also be aware of all of the side effects of the medications and any interactions the medication may have with food and/or other medications.

But what specifically can I ask my pharmacist?1 

  • OTC drugs
    • Currently there are so many non-prescription drugs out. There are also many different brands or types with the same active ingredient! Should you take Excedrin or Excedrin migraine? Which cough syrup will best treat my symptoms? Does brand really matter? Ask your pharmacist!
      • Common OTC topics: acne, allergies, cough and colds, lice infestation, contact lenses, GI distress (constipation, diarrhea, nausea), ear drops, eye drops, heartburn, and oral health.
  • New drug information
    • You just received a new prescription…did your doctor explain what to expect? Do you know the potential side effects, when to contact your doctor if it isn’t working? Can you breast feed with this medication? Are there any special instructions like avoid grapefruit juice or careful in the sun? Ask your pharmacist!
      • Common topics for new medications: Side effects, what to expect in terms of benefit, what the drug is used for, how to store it, how to apply/take the medication.
      • Make sure you understand HOW and WHY you are taking your medication!
  • Differentiate between different medications
    • Some patients have multiple medications. This also goes with the point above. Sometimes you may get a new prescription that then causes your daily medication regimen to become chaotic, confusing, and overwhelming.
    • Do you know which disease each drug is for? Are you confused by the names? Do you know when to take each pill to get the maximum benefit? Do you think you take too many medications and want to consolidate? Ask your pharmacist!
  • Discuss pricing
    • Some pharmacies have cheaper generics. You can ask your pharmacist about switching to generic medications to prevent high costs!
      • You can also check out www.Medtipster.com to find prescription drugs available on discount generic programs. Many drugs cost as little as $4!
  • Vaccinations
    • Need a flu shot? Need more vaccinations, such as shingles vaccine or a meningitis vaccine before you go off to college? Ask your pharmacist! An immunization certified pharmacist can administer the vaccine in the pharmacy.
  • Help manage chronic conditions, such as diabetes and hypertension
    • Using a glucometer and testing your sugar and blood pressure can be scary! Ask your pharmacist to help educate yourself on both your condition and how to best manage it. They will teach you how to use the glucometer and let you know the best times to test your blood sugar. Or they can teach you how to measure your own blood pressure, setting up a schedule to make sure you consistently monitor your own blood pressure.
  • New moms
    • Can you breast feed with your current medications? Are you taking enough vitamins? Which diaper rash cream is the best for my child? Are any wipes better than the others? Ask your pharmacist!
  • If you have any changes in your health/body and you just started taking a new prescription medication, ask your pharmacist! He/she may be able to let you know if it is normal and whether or not you should contact your doctor or not.

Next time you pick up a prescription, make sure you know exactly what to expect with the medication. Be an informed patient! The pharmacist is there to help you, use the resource! They spent many years in school learning about the medications. They have knowledge that they would love to share with you, especially if it helps you and improves your health!







1Ask A Pharmacist. (2014). Frequently Asked Questions. Retrieved from http://www.walgreens.com/topic/faqhome/faqlanding.jsp

2Simone, A. (December 18, 2013). Pharmacists Among Most Widely Trusted Professionals, Gallup Poll Finds. Pharmacy Times. Retrieved from http://www.pharmacytimes.com/

Tips for Reading Your Prescription Drug Formulary

www.Medtipster.com 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?

www.Medtipster.com 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 http://www.who.int/features/qa/84/en/ to learn more about myths and the truth behind them all.



1Center for Disease Control and Prevention (CDC). (2014). Retrieved from http://www.cdc.gov/

2The College of Physicians of Philadelphia. (2014). Diseases and Vaccines Timeline. The History of Vaccines. Retrieved from  http://www.historyofvaccines.org/content/timelines/diseases-and-vaccines

3Kearney, L. (April 24, 2014). California City Sees Spike in Whooping Cough Cases. Reuters Health Information. Retrieved from http://www.medscape.com/viewarticle/824067 

4Kelly, J. C. (June 02, 2014). Uptick in Worldwide Polio Cases in 2013 Continues Into 2014. Medscape Medical News. Retrieved fromhttp://www.medscape.com/viewarticle/826069  

5Lowes, R. (May 29, 2014). Measles Vaccine Refusal Helps Make 2014 a Record Year. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/825913

6World Health Organization. (April 2013). What are some of the myths- and facts- about vaccination? Retrieved from http://www.who.int/features/qa/84/en/

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

www.Medtipster.com 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

www.Medtipster.com 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, www.cdc.gov.


Vaccines: Remind members to get a flu shot!

www.Medtipster.com 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


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?

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, www.medtipster.com, 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.