Top Tips for Reducing Your Pharmaceuticals Budget

Jeffrey E. Keller MD

Objectives

Understand pharmaceutical pricing, including Acquisition Cost plus, Fill fees, Medicaid pricing and AWP.

Understand how to develop and maintain an appropriate formulary.

Understand how an OTC Commissary works.

How Are You Doing Now?

Calculate pharmacy costs per inmate per day.

<$0.50 per inmate per day = Excellent! $0.50-$1.00 per inmate per day = OK! $1.00-$1.50 per inmate per day = Average >$1.50 per inmate per day = Problem!

Rule Number One

Know how much everything costs!

Know the price of medications

Esterified Estrogen (Menest) $32.44

Conjugated estrogen (Premarin) $57.44

Estropipate (Ogen) $5.99

Estradiol (Estrace) $4.50

Pill Size Comparison

Generic Price Drops

It takes approximately two years after a drug goes generic for the price to drop to low price status.

Lamotrogene (Lamictal) What drugs went generic last year?

New Generic Drugs

Levetiracem (Keppra) Levofloxacin (Levaquin) Losartin (Cozaar) Zonisamide (Zonagram) Ceftriazone (Rocephin)

Reverse Generic Examples

Albuterol MDI Colchicine

Understand Pharmacy Pricing

Average Wholesale Price (AWP) FUL (Federal Upper Limit) MAC (Maximum Allowable Cost) Acquisition Cost Plus

AWP—Average Wholesale Price

AWP is not an average!

AWP is not wholesale!

AWP is not the price you want to pay!

HCFA Prices

Federal Upper Limit (FUL)

Maximum Allowable Cost (MAC)

MAC Price Lists

CIPROFLOXACIN 500MG TAB ER CIPRO XR 07/05/2011 9.41248

CIPROFLOXACIN HCL 100 MG TAB 07/05/2011 3.00066

CIPROFLOXACIN HCL 250 MG TAB CIPRO 07/05/2011 0.20731 CIPROFLOXACIN HCL 500 MG TAB CIPRO 07/05/2011 0.21659 CIPROFLOXACIN HCL 750 MG TAB CIPRO 07/05/2011 0.26908 CITALOPRAM 10 MG/5 ML SOLN CELEXA 07/05/2011 0.17737 CITALOPRAM HBR 10 MG TAB CELEXA 07/05/2011 0.04710 CITALOPRAM HBR 20 MG TAB CELEXA 07/05/2011 0.05036 CITALOPRAM HBR 40 MG TAB CELEXA 07/05/2011 0.06135

Compare Prices to Medicaid MAC

If you are paying more than MAC, negotiate lower prices.

Acquisition Price Plus

Prices fluctuate day to day. Set routine to spot check prices

Fill Fees

Fee pharmacy charges for filling prescription Should not be over $5.00 Often the most important part of fee

Fill Fees

Cost of Prescription for 1 HCTZ tablet:– $0.01 + $4.00 = $4.01

Cost of 30 HCTZ tablets– $0.30 + $4.00 = $4.30

Tips for reducing fill fees

50mg po qAM, 100mg po qPM– TWO fill fees

50mg one po qAM and 2 po qPM– ONE fill fee

Wastage

Opened meds cannot legally be reused Source of significant waste

Tips for Reducing Wastage

Institute dosage changes after current month’s prescription finishes

Check Pharmacy Bill

Mistakes common $44.77? Or $4.77?

Formulary

Formularies are the Community Standard of Care

Formularies, properly done, do NOT restrict access to appropriate medicine

Formulary

Consider a formulary a “Pre-Approved Medication list”

If a medication is not on the formulary, that does NOT mean you cannot prescribe it.

It means you have to get approval first. Reason could be price. Or not.

Formulary--Price

Should you use Nexium? Or Omeprazole?

Formulary--Convenience

Bupropion? Or Bupropion SR?

Formulary—Controlled Drugs

Ultram Ambien Soma

Formulary

Yes-No $-$$-$$$-$$$$-$$$$$

OTC Commissary

Compare access to OTC medications in the community with inside corrections

OTC commissary

What is the Time Cost to the medical staff of dealing with OTC requests?

OTC Commissary

OTC Commissary MUST be cheaper for the inmate than going through sick call.

OTC Commissary

OTC Meds inappropriate for corrections Dextromethorphan Ephedrine, pseudoephedrine Ex-Lax

OTC Commissary

How to handle Indigency It still may be cheaper to give indigent

inmates OTC medications.

OTC Commissary Examples

Pain Relievers—Ibuprofen Skin Meds—Antifungal, steroid cream Acne meds—Stridex, Benzoyl Stomache—Ranitidine, omeprazole Constipation—Fiber, colace

OTC Commissary Examples

Diet supplements—Vitamins, lactaid Cold and flu—cough drops, loratidine Eyes—allergy eye drops Psoriasis meds—coal tar

Special Cases

Psychiatric Medications May be 40-60% of your total pharmacy bill

Psychiatric Medications

Seroquel  400mg- $417.02                600mg- $623.75 Zyprexa    10mg- $455.61                 15mg- $681.64 Risperdal    2mg- $6.25                   4mg- $7.83 Prolixin        5mg- $5.86                   10mg- $6.38 Haldol          5mg- $6.00 10mg- $20.15

Psychiatric Medications

Polypharmacy Jail vs outside considerations Fluidity of treatment Drug abuse

HIV Hepatitis C

Treatment algorhythm Off-on treatment worse than no treatment at

all

Treatment Guidelines

Clinical Criteria designed to avoid unnecessary medication prescriptions

CDC RecommendationsPharyngitis

Four Clinical Criteria1. Fever

2. Exudate

3. Lymphadenopathy

4. NO cough

CDC RecommendationsSinusitis

1. Symptoms for more than 7 days.

2. Pain or tenderness of face or teeth

3. Purulent nasal discharge.

4. Moderate to severe symptoms.

CDC RecommendationsBronchitis

No Pneumonia—No Antibiotics

1. No Fever

2. No tachypnea

3. No asymmetric crackles

SSRI Dosing

For most drugs (SSRIs), raising the dose beyond the usual therapeutic range does not speed up response but rather causes greater severity of side effects (TREATMENTS OF PSYCHIATRIC DISORDERS - 3rd Ed.)

For sertraline, the dose is 50 mg once daily for almost all patients (Cecil Textbook of Medicine, 21st ed).

For fluoxetine, it is well established that doses higher than 20 mg per day do not produce a better therapeutic response in most patients (Schweizer et al 1990).

SSRI Dosing

The established minimum effective dose of paroxetine is 20 mg per day. Doses higher than 20 mg per day have not been documented to improve percentage of response or response rate (Grimsley 1992)

There is little evidence that total daily doses of fluvoxamine greater than 150 mg provide added efficacy.

Atypical Antipsychotics vs. Traditional Antipsychotics

Atypical Antipsychotics in the Treatment of Schizophrenia: Systematic Overview and Meta-regression Analysis. Geddes, J. and Bebbington, P.

BMJ 2000; 321: 1371-1376. Meta-analysis of 52

Randomized trials comparing atypical antipsychotics with conventional antipsychotics

No difference in symptom reduction if conventional dose is less than 12mg per day.

Atypicals do cause less extra-pyramidal symptoms, but the overall tolerability is identical between groups.

“There is no clear evidence that atypical antipsychotics are more effective or are better tolerated than conventional antipsychotics.”

The Best of the Best Information Sources

1. Primary Care Medical Abstracts

2. The Oregon Drug Utilization Review Newsletter

3. The Prescriber’s Letter