Towards ‘Values-Based’ formularies:
Generic uptake, sustainability and safety.
Value of Generics Conference
Montreal, P.Q.
October 26, 2011.
Alan Cassels,
University of Victoria.
cassels@uvic.ca
I am
Supported by
research
grants,
contracts
related to
health reporting
and a UVIC
research salary
The “learning” objectives:
• Look at some data on current trends in drug
spending
• Recount some examples of how people
typically receive drugs and drug coverage.
• Suggest ways that drug coverage can become
more cost-effective, rationale and safe.
What do we hear from employees
regarding drug coverage?
• “If the doctor prescribes it, I must need it
and my plan must therefore cover it.”
• “Sure, newer drugs are more expensive,
but you get what you pay for, right?
• “My doctor gives me free samples
because he cares about my health and the
cost of the drugs.”
• “My drugs don’t cost me anything, they’re
free. “
Seeking Solutions to the Drug
Benefit Cost Crisis*
• Most employer-sponsored drug coverage
involves no deductible; most provide 80 to
100% coinsurance.
• More than half of employers have plans with
no formulary (open formulary or few
formulary restrictions).
• Despite concerns about escalating costs,
employers are wearing most of the cost
burden.
• Employers are looking for new ways to
respond to growing prescription drug costs.
*survey report my group carried out in 2005 of major employers in Canada
about trends in drug benefit cost control.
PLAN DESIGN
•Co-insurance
•Benefit maximums
•Drug formularies
•Benefit levels
What are some of the
ways drug plans
control costs?
COST AVOIDANCE
•Wellness programs
•Absence management
•Education/awareness
•Legislative shifting
•Benefit formulas
COST SHARING
•Employee/member contributions
•Flex benefits
•Health care spending accounts
Change the plan
design,
avoid costs or
share costs
What are we actually covering?
Top Therapeutic Classifications 2009
Avg Cost
by Disease colour
% Paid
1) Cholesterol disorders $72.60
9.8%
2) Blood pressure
$31.66
7.9%
3) Diabetes
$51.67
6.8%
4) Depression
$45.69
6.7%
5) Ulcers
$52.98
6.4%
6) Rheumatoid Arthritis $1,674.60
5.7%
7) Asthma and other Inflammatory Diseases
47.09
5.5%
8) Antibiotics/Anti-infectives
$27.56
4.9%
9) Narcotic Analgesics $27.28
3.2%
10) Skin Disorders
$34.10
3.0%
GREEN
PINK
YELLOW
Top 25*
RANK
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NAME
REMICADE INJECTION
NEXIUM 40MG TABLET
CRESTOR 10MG TABLET
HUMIRA 40MG/0.8ML PFS INJ
ENBREL 50MG INJECTION
PLAVIX 75MG TABLET
CRESTOR 20MG TABLET
EZETROL 10MG TABLET
SYMBICORT 200 TURBUHALER
CELEBREX 200MG CAPSULE
CIPRALEX 10MG TABLET
COPAXONE 20MG/ML PFS
CYMBALTA 60MG DR CAPSULE
16
ADVAIR 250UG INHALATION DISKUS
SINGULAIR 10MG TABLET
NEULASTA 10MG/ML PFS WITH ULTRASAFE
NEEDLE GUARD
17
18
NASONEX AQ. NASAL SPRAY 50MCG
CRESTOR 5MG TABLET
19
20
21
22
23
24
25
ONE TOUCH ULTRA BLUE TEST STRIP (ON)
LYRICA 75MG CAPSULE
SPIRIVA 18MCG CAPSULE
JANUVIA 100MG TABLET
AVONEX PS 30MCG/0.5ML SYR
CIPRALEX 20MG TABLET
LIPITOR 20MG TABLET
SCRIPTS
12,625
355,983
399,830
13,533
12,145
145,387
168,238
142,409
143,506
191,909
139,645
7,655
66,659
DIN COST PAID
54,759,926
34,766,372
34,495,778
28,728,311
25,471,235
18,907,467
18,023,262
15,443,547
15,412,380
12,652,487
12,356,598
12,255,407
11,631,880
COST PER SCRIPT
$4,337.42
$97.66
$86.28
$2,122.83
$2,097.26
$130.05
$107.13
$108.45
$107.40
$65.93
$88.49
$1,600.97
$174.50
82,897
80,372
11,213,330
10,332,257
$135.27
$128.56
3,890
10,316,165
$2,651.97
270,974
110,289
9,991,909
9,136,643
$36.87
$82.84
77,488
57,003
72,619
51,548
4,099
79,711
71,644
8,790,169
8,288,399
8,167,883
8,159,687
7,506,267
7,433,866
7,205,873
$113.44
$145.40
$112.48
$158.29
$1,831.24
$93.26
$100.58
* Based on 2009 data from Telus, the pay-direct drug card provider for Sun Life, Great-West Life, Standard Life and other group insurance companies in Canada. The top drugs
represent 10,651,541 prescriptions at a cost of $982,676,747 and an average cost per prescription of $92.25.
Next top 25
RANK
26
NAME
REBIF 44MCG (12MIU) PFS
SCRIPTS
3,523
DIN COST PAID
7,174,368
COST PER SCRIPT
$2,036.44
27
28
APO-ATORVASTATIN 20MG TABLET
LEVEMIR PENFILL
120,089
37,657
7,095,108
6,854,048
$59.08
$182.01
29
TEVA-VENLAFAXINE XR 75MG ER CAPSULE
112,158
6,580,955
$58.68
30
FLOVENT HFA 250MCG INHALER (AEROSOL)
63,547
6,553,955
$103.14
31
32
33
34
35
ADVAIR 500UG INHALATION DISKUS
LIPITOR 10MG TABLET
ADVAIR 250MCG MD INHALER
BOTOX 50U/100U/200U VIAL
GLEEVEC 400MG TABLET
33,323
79,872
35,429
8,654
1,507
6,538,657
6,524,926
6,280,752
6,215,217
6,099,776
$196.22
$81.69
$177.28
$718.19
$4,047.63
36
37
STELARA 45MG/0.5ML INJECTION
DIOVAN 80MG TABLET
1,141
77,154
5,871,635
5,676,420
$5,146.04
$73.57
38
39
NOVORAPID 100U/ML INSULIN CARTRIDGE
MICARDIS 80MG TABLET
56,239
76,465
5,626,102
5,549,471
$100.04
$72.58
40
41
APO-ATORVASTATIN 10MG TABLET
CONTOUR TEST STRIP (ON)
115,972
48,856
5,530,186
5,488,058
$47.69
$112.33
42
43
44
45
46
47
48
LANTUS SOLOSTAR 100U/ML PREFILL PEN 5X3ML
BIAXIN 500MG XL TABLET
NEUPOGEN 300MCG/ML VIAL
AVAPRO 150MG TABLET
CRESTOR 40MG TABLET
COVERSYL 8MG TABLET
BETASERON 0.3MG VIAL
37,986
103,797
3,577
72,976
45,109
71,780
2,590
5,427,347
5,391,436
5,379,047
5,369,313
5,251,928
5,236,177
5,189,359
$142.88
$51.94
$1,503.79
$73.58
$116.43
$72.95
$2,003.61
49
PROMETRIUM 100MG CAPSULE
76,357
5,155,094
$67.51
50
FLOVENT HFA 125MCG INHALER (AEROSOL)
99,963
5,072,999
$50.75
51
APO-LANSOPRAZOLE 30MG CAPSULE
104,748
5,063,848
$48.34
Sheila’s got heartburn…
• Office Administrator. 34 years old
• She has been taking Losec (omeprazole) for
years. It works great.
• She feels it’s worth every penny of the $112
per month. Her plan is a 20% deductible so
her cost is $22 per month; employer pays $90.
• What’s wrong with this picture?
Sheila’s Story
• Has her doctor ever tried her on over-thecounter treatments for heartburn or “older
but proven” H2-antagonists?
• Does she know her benefit plan pays twice as
much as it could/should for her heartburn?
• Does she know that PPI users have a higher
risk of pneumonia and infection with Cdifficile and that long-term use of PPIs is
associated with an increased risk of certain
bone fractures?
• Many provinces have PPIs under “Special
Authority” (prior authorization) so why
doesn’t her private drug plan follow?
Proton Pump Inhibitors
PPIS
RANK
NAME
SCRIPTS
DIN COST PAID GENERIC NAME
COST PER SCRIPT
86
LOSEC 20MG SR TABLET
31,342
3,526,819 OMEPRAZOLE MAGNESIUM
$112.53
72
PANTOLOC 40MG TABLET
46,986
PANTOPRAZOLE SOD
3,968,654 SESQUIHYDRATE
$84.46
97
PREVACID 30MG CAPSULE
37,861
3,178,019 LANSOPRAZOLE
$83.94
139
RATIO-OMEPRAZOLE 20MG SR TABLET
40,657
2,335,652 OMEPRAZOLE MAGNESIUM
$57.45
146
MYLAN-OMEPRAZOLE 20MG DR CAPSULE
39,440
2,234,249 OMEPRAZOLE
$56.65
55
APO-OMEPRAZOLE 20MG CAPSULE
92,286
4,949,920 OMEPRAZOLE
$53.64
110
NOVO-LANSOPRAZOLE 30MG CAPSULE
59,236
2,901,782 LANSOPRAZOLE
$48.99
80
APO-PANTOPRAZOLE 40MG TABLET
77,387
3,765,016 PANTOPRAZOLE SODIUM
$48.65
51
APO-LANSOPRAZOLE 30MG CAPSULE
104,748
5,063,848 LANSOPRAZOLE
$48.34
187
SANDOZ PANTOPRAZOLE 40MG TABLET
36,953
1,746,831 PANTOPRAZOLE
$47.27
193
TEVA-PANTOPRAZOLE 40MG TABLET
36,358
1,705,965 PANTOPRAZOLE SODIUM
$46.92
58
RAN-PANTOPRAZOLE 40MG TABLET
102,136
4,667,691 PANTOPRAZOLE SODIUM
$45.70
213
TECTA 40MG EC TABLET
42,947
1,588,876 PANTOPRAZOLE MAGNESIUM
$37.00
186
RAN-RABEPRAZOLE 20MG EC TABLET
52,009
1,749,680 RABEPRAZOLE SODIUM
$33.64
64
TEVA-RABEPRAZOLE EC 20MG TABLET
137,468
4,336,467 RABEPRAZOLE SODIUM
$31.55
937,814
47,719,468
$50.88
Proton Pump Inhibitors
PPIS
RANK
NAME
SCRIPTS
DIN COST PAID GENERIC NAME
OMEPRAZOLE
31,342 3,526,819 MAGNESIUM
COST PER SCRIPT
86
LOSEC 20MG SR TABLET
$112.53
72
PANTOLOC 40MG TABLET
46,986
PANTOPRAZOLE SOD
3,968,654 SESQUIHYDRATE
$84.46
97
PREVACID 30MG CAPSULE
37,861
3,178,019 LANSOPRAZOLE
$83.94
55
RATIO-OMEPRAZOLE 20MG SR
TABLET
MYLAN-OMEPRAZOLE 20MG DR
CAPSULE
APO-OMEPRAZOLE 20MG CAPSULE
110
NOVO-LANSOPRAZOLE 30MG CAPSULE
59,236
2,901,782 LANSOPRAZOLE
$48.99
80
APO-PANTOPRAZOLE 40MG TABLET
77,387
3,765,016 PANTOPRAZOLE SODIUM
$48.65
51
APO-LANSOPRAZOLE 30MG CAPSULE
104,748
5,063,848 LANSOPRAZOLE
$48.34
187
SANDOZ PANTOPRAZOLE 40MG TABLET
36,953
1,746,831 PANTOPRAZOLE
$47.27
193
TEVA-PANTOPRAZOLE 40MG TABLET
36,358
1,705,965 PANTOPRAZOLE SODIUM
$46.92
58
RAN-PANTOPRAZOLE 40MG TABLET
102,136
4,667,691 PANTOPRAZOLE SODIUM
$45.70
213
TECTA 40MG EC TABLET
42,947
1,588,876 PANTOPRAZOLE MAGNESIUM
$37.00
186
RAN-RABEPRAZOLE 20MG EC TABLET
52,009
1,749,680 RABEPRAZOLE SODIUM
$33.64
64
TEVA-RABEPRAZOLE EC 20MG TABLET
137,468
4,336,467 RABEPRAZOLE SODIUM
$31.55
139
146
OMEPRAZOLE
40,657 2,335,652 MAGNESIUM
$57.45
39,440 2,234,249 OMEPRAZOLE
92,286 4,949,920 OMEPRAZOLE
$56.65
$53.64
937,814
47,719,468
$50.88
PPI Special
authority
form,
BC
Pharmacare
What is the basis for BC PharmaCare’s “Special
Authority” process around PPIs?
• Evidence show that all PPIs are equally effective for the treatment of
common acid-reflux conditions.
• PharmaCare’s first-covered PPI for patients eligible for Special Authority
approval was previously rabeprazole (Pariet® and generics).
• On January 26, 2010, PharmaCare coverage was expanded for the PPIs,
and pantoprazole Mg was added as another first-covered PPI for patients
eligible for Special Authority approval. These patients now have two PPI
options - rabeprazole and pantoprazole Mg – with one Special Authority
approval.
• Patients become eligible after first trying ranitidine (Zantac® and
generics), cimetidine (Tagamet® and generics), or a similar drug.
•
Excerpts from Pharmacare memo January 26, 2010
Peter has hypertension…
• Retired hospital technician. 74 years old
• Told he has “uncontrolled hypertension.”
• First drug given to him is a free sample:
Diovan (valsartan)—it’s an ARB
• It seems to ‘work’. His municipal pension plan
covers 80% ($60) of its 75$/ month cost.
• “My doctor is great. He gave me the best”
• What’s wrong with this picture?
Peter’s Story: The reality
• Does he know there are many non-drug approaches to
treating hypertension; reduced salt diet, etc?
• Does his doctor know that free samples are always the
newest, most expensive, least studied drug?
• Does his doctor know the guidelines saying a drug like
Diovan is a 4th line treatment (after a diuretic, an ACEInhibitor and maybe a Beta-blocker)?
• Why would his drug plan pay 75$ a month instead of a
better treatment costing only $15 per month?
• If his plan was guided by similar rules to BC Pharmacare’s
formulary rules he’d need to try an ACE-inhibitor first.
• The Municipal Pension plan got rid of its dental coverage
and may dump its drug coverage. Why? It’s unsustainable.
Top drugs for hypertension
RANK
NAME
SCRIPTS
DIN COST PAID GENERIC NAME
COST PER SCRIPT
37
DIOVAN 80MG TABLET
77,154
5,676,420 VALSARTAN
$73.57
39
MICARDIS 80MG TABLET
76,465
5,549,471 TELMISARTAN
$72.58
45
AVAPRO 150MG TABLET
72,976
5,369,313 IRBESARTAN
$73.58
47
COVERSYL 8MG TABLET
71,780
5,236,177 PERINDOPRIL ERBUMINE
$72.95
56
ATACAND 16MG TABLET
62,464
4,949,782 CANDESARTAN CILEXETIL
$79.24
65
DIOVAN 160MG TABLET
55,611
4,297,484 VALSARTAN
$77.28
67
COVERSYL 4MG TABLET
83,116
4,143,479 PERINDOPRIL ERBUMINE
$49.85
70
AVAPRO 300MG TABLET
54,848
4,044,720 IRBESARTAN
$73.74
82
ATACAND 8MG TABLET
52,148
3,717,417 CANDESARTAN CILEXETIL
$71.29
85
ATACAND PLUS 16/12.5MG TABLET
47,947
3,591,600 CANDESARTAN CILEXETIL/HCTZ
$74.91
90
MICARDIS PLUS 80MG/12.5MG TABLET
49,353
3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE
$69.53
93
APO-RAMIPRIL 10MG CAPSULE
90,943
3,280,945 RAMIPRIL
$36.08
98
AVALIDE 300MG/12.5MG TABLET
45,785
3,175,360 IRBESARTAN/HCTZ
$69.35
99
DIOVAN-HCT 160/12.5MG TABLET
44,245
3,171,984 VALSARTAN/HCTZ
$71.69
111
COZAAR 50MG TABLET
33,517
2,798,256 LOSARTAN POTASSIUM
$83.49
127
DIOVAN-HCT 160MG/25MG TABLET
35,047
2,562,292 VALSARTAN/HCTZ
$73.11
130
COVERSYL PLUS 4MG/1.25MG TABLET
37,216
2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE
$67.44
151
COZAAR 100MG TABLET
27,196
2,188,671 LOSARTAN POTASSIUM
$80.48
155
TEVA-RAMIPRIL 10MG CAPSULE
55,150
2,150,252 RAMIPRIL
$38.99
160
AVALIDE 150MG/12.5MG TABLET
29,351
2,074,953 IRBESARTAN/HCTZ
$70.69
170
HYZAAR DS (100MG/25MG) TABLET
27,558
1,984,045 LOSARTAN POTASSIUM/HCTZ
$72.00
178
DIOVAN-HCT 80/12.5MG TABLET
27,066
1,881,902 VALSARTAN/HCTZ
$69.53
190
AVALIDE 300MG/25MG TABLET
25,264
1,717,448 IRBESARTAN/HCTZ
$67.98
191
RAN-RAMIPRIL 10MG CAPSULE
35,952
1,707,648 RAMIPRIL
$47.50
219
APO-RAMIPRIL 5MG CAPSULE
59,613
1,514,414 RAMIPRIL
$25.40
222
MICARDIS 40MG TABLET
22,540
1,499,432 TELMISARTAN
$66.52
1,300,305
84,224,985
$64.77
Top drugs for hypertension
RANK
NAME
SCRIPTS
DIN COST PAID GENERIC NAME
DIOVAN 80MG TABLET
39
MICARDIS 80MG TABLET
76,465
5,549,471 TELMISARTAN
$72.58
45
AVAPRO 150MG TABLET
72,976
5,369,313 IRBESARTAN
$73.58
47
COVERSYL 8MG TABLET
71,780
5,236,177 PERINDOPRIL ERBUMINE
$72.95
56
ATACAND 16MG TABLET
62,464
4,949,782 CANDESARTAN CILEXETIL
$79.24
65
DIOVAN 160MG TABLET
55,611
4,297,484 VALSARTAN
$77.28
67
COVERSYL 4MG TABLET
83,116
4,143,479 PERINDOPRIL ERBUMINE
$49.85
70
AVAPRO 300MG TABLET
54,848
4,044,720 IRBESARTAN
$73.74
82
ATACAND 8MG TABLET
52,148
3,717,417 CANDESARTAN CILEXETIL
$71.29
85
ATACAND PLUS 16/12.5MG TABLET
47,947
3,591,600 CANDESARTAN CILEXETIL/HCTZ
$74.91
90
MICARDIS PLUS 80MG/12.5MG TABLET
49,353
3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE
$69.53
93
APO-RAMIPRIL 10MG CAPSULE
90,943
3,280,945 RAMIPRIL
$36.08
98
AVALIDE 300MG/12.5MG TABLET
45,785
3,175,360 IRBESARTAN/HCTZ
$69.35
99
DIOVAN-HCT 160/12.5MG TABLET
44,245
3,171,984 VALSARTAN/HCTZ
$71.69
111
COZAAR 50MG TABLET
33,517
2,798,256 LOSARTAN POTASSIUM
$83.49
127
DIOVAN-HCT 160MG/25MG TABLET
35,047
2,562,292 VALSARTAN/HCTZ
$73.11
130
COVERSYL PLUS 4MG/1.25MG TABLET
37,216
2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE
$67.44
151
COZAAR 100MG TABLET
27,196
2,188,671 LOSARTAN POTASSIUM
$80.48
155
TEVA-RAMIPRIL 10MG
CAPSULE
160
AVALIDE 150MG/12.5MG TABLET
29,351
2,074,953 IRBESARTAN/HCTZ
$70.69
170
HYZAAR DS (100MG/25MG) TABLET
27,558
1,984,045 LOSARTAN POTASSIUM/HCTZ
$72.00
178
DIOVAN-HCT 80/12.5MG TABLET
27,066
1,881,902 VALSARTAN/HCTZ
$69.53
190
AVALIDE 300MG/25MG TABLET
25,264
1,717,448 IRBESARTAN/HCTZ
$67.98
219
RAN-RAMIPRIL 10MG
CAPSULE
APO-RAMIPRIL 5MG
CAPSULE
222
MICARDIS 40MG TABLET
191
77,154 5,676,420 VALSARTAN
COST PER SCRIPT
37
55,150 2,150,252 RAMIPRIL
$73.57
$38.99
35,952 1,707,648 RAMIPRIL
$47.50
59,613 1,514,414 RAMIPRIL
$25.40
22,540
1,499,432 TELMISARTAN
$66.52
Savings if you covered blood pressure pills according to
the guidelines?
What if the most effective, guideline-approved drug was the one
prescribed first?
– Diovan: 77,000 prescriptions, total cost $5.6 million.
– Generic ramipril: $43 per script would cost $3.3 million
– Generic hydrocholorothiazide: $2.45 per script would cost $188,000
Marge has ‘high’ cholesterol
•
•
•
•
•
University sociologist: 54 years old
Told she has “high cholesterol”.
She asks for a generic; gets generic atorvastatin.
It costs 50% of the brand ($50 instead of $100)
Needs a ‘boost’ so her doctor gives her a sample
of Ezetrol (ezetimibe)$108/ month
• “My doctor is great. He really cares about
bringing my cholesterol down.”
• What’s wrong with this picture?
Marge’s Story
• Treating “high cholesterol” in women is
unproven.
• A study released in January 2008 showed
ezetimibe had no benefit on the buildup of
arterial plaque when compared with patients
taking only statins. $108 for no added benefit?
• Side effects include: Rhabdomyolysis - severe
muscle damage including pain, tenderness,
weakness and liver damage.
• Marge wonders why she feels weak all the time.
Statins: drugs to lower cholesterol
RANK
NAME
SCRIPTS
DIN COST PAID GENERIC NAME
5,251,928 ROSUVASTATIN CALCIUM
COST PER SCRIPT
46
CRESTOR 40MG TABLET
45,109
$116.43
8
EZETROL 10MG TABLET
142,409
15,443,547 EZETIMIBE
$108.45
7
CRESTOR 20MG TABLET
168,238
18,023,262 ROSUVASTATIN CALCIUM
$107.13
66
LIPITOR 40MG TABLET
40,018
4,209,578 ATORVASTATIN CALCIUM
$105.19
25
LIPITOR 20MG TABLET
71,644
7,205,873 ATORVASTATIN CALCIUM
$100.58
232
LIPITOR 80MG TABLET
14,515
1,422,804 ATORVASTATIN CALCIUM
$98.02
3
CRESTOR 10MG TABLET
399,830
34,495,778 ROSUVASTATIN CALCIUM
$86.28
18
CRESTOR 5MG TABLET
110,289
9,136,643 ROSUVASTATIN CALCIUM
$82.84
32
LIPITOR 10MG TABLET
79,872
6,524,926 ATORVASTATIN CALCIUM
$81.69
154
LIPIDIL EZ 145MG TABLET
34,986
2,160,978 FENOFIBRATE
$61.77
63
APO-ATORVASTATIN 40MG TABLET
73,671
4,383,327 ATORVASTATIN CALCIUM
$59.50
27
APO-ATORVASTATIN 20MG TABLET
120,089
7,095,108 ATORVASTATIN CALCIUM
$59.08
246
APO-ATORVASTATIN 80MG TABLET
23,730
1,351,439 ATORVASTATIN CALCIUM
$56.95
40
APO-ATORVASTATIN 10MG TABLET
115,972
5,530,186 ATORVASTATIN CALCIUM
$47.69
1,440,372
122,235,377
$84.86
Statins: drugs to lower cholesterol
RANK
NAME
46
CRESTOR 40MG TABLET
8
EZETROL 10MG TABLET
7
CRESTOR 20MG TABLET
66
SCRIPTS
DIN COST PAID GENERIC NAME
45,109
5,251,928 ROSUVASTATIN CALCIUM
142,409 15,443,547 EZETIMIBE
COST PER SCRIPT
$116.43
$108.45
168,238
18,023,262 ROSUVASTATIN CALCIUM
$107.13
LIPITOR 40MG TABLET
40,018
4,209,578 ATORVASTATIN CALCIUM
$105.19
25
LIPITOR 20MG TABLET
71,644
7,205,873 ATORVASTATIN CALCIUM
$100.58
232
LIPITOR 80MG TABLET
14,515
1,422,804 ATORVASTATIN CALCIUM
$98.02
3
CRESTOR 10MG TABLET
399,830
34,495,778 ROSUVASTATIN CALCIUM
$86.28
18
CRESTOR 5MG TABLET
110,289
9,136,643 ROSUVASTATIN CALCIUM
$82.84
32
LIPITOR 10MG TABLET
79,872
6,524,926 ATORVASTATIN CALCIUM
$81.69
154
LIPIDIL EZ 145MG TABLET
34,986
2,160,978 FENOFIBRATE
$61.77
63
APO-ATORVASTATIN 40MG TABLET
73,671
4,383,327 ATORVASTATIN CALCIUM
$59.50
27
APO-ATORVASTATIN 20MG TABLET
120,089
7,095,108 ATORVASTATIN CALCIUM
$59.08
246
APO-ATORVASTATIN
80MG TABLET
40
APO-ATORVASTATIN 10MG TABLET
23,730
115,972
1,440,372
1,351,439 ATORVASTATIN CALCIUM $56.95
5,530,186 ATORVASTATIN CALCIUM
122,235,377
$47.69
$84.86
What values would a “Values-based”
formulary be based on?
• Full access to the “best” medications.
• Best?
– NEWEST
– MOST COSTLY
– MOST ADVERTISED
– MOST SEXY
– MOST ADVANCED
– MOST TALKED ABOUT
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What values would a “Values-based”
formulary be based on?
• Full access to the “best” medications.
• Best?
– Best in effectiveness
– Best in cost effectiveness
– Best in safety
– Best in terms of a proven track record (no surprises)
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What these stories tell us?
• Free samples are gateway drugs to higher drug
spending and poor prescribing.
• Private drug plans who “pay for everything” often
disregard the concept of comparative cost
effectiveness. Employees and employers suffer.
• Both employees and employers should avoid a drug
plan that provides automatic coverage of:
• More expensive drugs vs. less expensive drugs that are
equally effective.
• Brand names vs. generic drugs which do the same thing.
• Newer drugs of unknown benefit vs. older proven
therapies.
• Drugs of questionable safety vs. drugs whose safety
profile we know.
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“Managing” the formulary.
• Needs an independent, high quality source of drug
information for payers, patients and prescribers.
• Three key elements: prior authorization, generic
substitution and therapeutic substitution.
• Involves other costs, especially education and
communications.
• Employees need to be incented to seek value in their
prescriptions. “They don’t cost anything, they’re free!”
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What role do plan sponsors have in
educating their members who believe?:
• “If the doctor prescribes it, I must need it and
my plan must pay for it.”
• “Newer drugs are more expensive, but they
are always going to be better. You pay for
what you get, right?”
• “The drugs don’t cost me anything, they’re
free.“
Conclusions
• ‘Newer’ never automatically mean ‘more
effective.’
• Communicating ‘value for money’ to payers,
patients and prescribers would help improve
rational use of drugs.
• Think of drug coverage in terms of “What is it
that we value?”
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How to contact me:
Alan Cassels
University of Victoria
cassels@uvic.ca
250 361 3120