Download - Controlling Pharmacy Costs in Corrections
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Top Tips for Reducing Your Pharmaceuticals Budget
Jeffrey E. Keller MD
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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.
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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!
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Rule Number One
Know how much everything costs!
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Know the price of medications
Esterified Estrogen (Menest) $32.44
Conjugated estrogen (Premarin) $57.44
Estropipate (Ogen) $5.99
Estradiol (Estrace) $4.50
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Pill Size Comparison
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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?
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New Generic Drugs
Levetiracem (Keppra) Levofloxacin (Levaquin) Losartin (Cozaar) Zonisamide (Zonagram) Ceftriazone (Rocephin)
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Reverse Generic Examples
Albuterol MDI Colchicine
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Understand Pharmacy Pricing
Average Wholesale Price (AWP) FUL (Federal Upper Limit) MAC (Maximum Allowable Cost) Acquisition Cost Plus
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AWP—Average Wholesale Price
AWP is not an average!
AWP is not wholesale!
AWP is not the price you want to pay!
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HCFA Prices
Federal Upper Limit (FUL)
Maximum Allowable Cost (MAC)
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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
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Compare Prices to Medicaid MAC
If you are paying more than MAC, negotiate lower prices.
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Acquisition Price Plus
Prices fluctuate day to day. Set routine to spot check prices
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Fill Fees
Fee pharmacy charges for filling prescription Should not be over $5.00 Often the most important part of fee
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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
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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
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Wastage
Opened meds cannot legally be reused Source of significant waste
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Tips for Reducing Wastage
Institute dosage changes after current month’s prescription finishes
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Check Pharmacy Bill
Mistakes common $44.77? Or $4.77?
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Formulary
Formularies are the Community Standard of Care
Formularies, properly done, do NOT restrict access to appropriate medicine
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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.
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Formulary--Price
Should you use Nexium? Or Omeprazole?
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Formulary--Convenience
Bupropion? Or Bupropion SR?
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Formulary—Controlled Drugs
Ultram Ambien Soma
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Formulary
Yes-No $-$$-$$$-$$$$-$$$$$
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OTC Commissary
Compare access to OTC medications in the community with inside corrections
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OTC commissary
What is the Time Cost to the medical staff of dealing with OTC requests?
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OTC Commissary
OTC Commissary MUST be cheaper for the inmate than going through sick call.
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OTC Commissary
OTC Meds inappropriate for corrections Dextromethorphan Ephedrine, pseudoephedrine Ex-Lax
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OTC Commissary
How to handle Indigency It still may be cheaper to give indigent
inmates OTC medications.
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OTC Commissary Examples
Pain Relievers—Ibuprofen Skin Meds—Antifungal, steroid cream Acne meds—Stridex, Benzoyl Stomache—Ranitidine, omeprazole Constipation—Fiber, colace
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OTC Commissary Examples
Diet supplements—Vitamins, lactaid Cold and flu—cough drops, loratidine Eyes—allergy eye drops Psoriasis meds—coal tar
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Special Cases
Psychiatric Medications May be 40-60% of your total pharmacy bill
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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
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Psychiatric Medications
Polypharmacy Jail vs outside considerations Fluidity of treatment Drug abuse
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HIV Hepatitis C
Treatment algorhythm Off-on treatment worse than no treatment at
all
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Treatment Guidelines
Clinical Criteria designed to avoid unnecessary medication prescriptions
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CDC RecommendationsPharyngitis
Four Clinical Criteria1. Fever
2. Exudate
3. Lymphadenopathy
4. NO cough
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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.
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CDC RecommendationsBronchitis
No Pneumonia—No Antibiotics
1. No Fever
2. No tachypnea
3. No asymmetric crackles
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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).
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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.
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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.”
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The Best of the Best Information Sources
1. Primary Care Medical Abstracts
2. The Oregon Drug Utilization Review Newsletter
3. The Prescriber’s Letter