Controlling Pharmacy Costs in Corrections

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  • You will be offered AWP minus some such percent, like AWP minus 12%. Sounds great, right.
  • Controlling Pharmacy Costs in Corrections

    1. 1. Top Tips for Reducing Your Pharmaceuticals Budget Jeffrey E. Keller MD
    2. 2. 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.
    3. 3. 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!
    4. 4. Rule Number OneKnow how much everything costs!
    5. 5. Know the price of medicationsEsterified Estrogen (Menest) $32.44Conjugated estrogen (Premarin) $57.44Estropipate (Ogen) $5.99Estradiol (Estrace) $4.50
    6. 6. Pill Size Comparison
    7. 7. Generic Price Drops Ittakes 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?
    8. 8. New Generic Drugs Levetiracem (Keppra) Levofloxacin (Levaquin) Losartin (Cozaar) Zonisamide (Zonagram) Ceftriazone (Rocephin)
    9. 9. Reverse Generic Examples AlbuterolMDI Colchicine
    10. 10. Understand Pharmacy Pricing Average Wholesale Price (AWP) FUL (Federal Upper Limit) MAC (Maximum Allowable Cost) Acquisition Cost Plus
    11. 11. AWP—Average Wholesale Price AWP is not an average! AWP is not wholesale! AWP is not the price you want to pay!
    12. 12. HCFA Prices Federal Upper Limit (FUL) Maximum Allowable Cost (MAC)
    13. 13. 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
    14. 14. Compare Prices to Medicaid MAC Ifyou are paying more than MAC, negotiate lower prices.
    15. 15. Acquisition Price Plus Prices fluctuate day to day. Set routine to spot check prices
    16. 16. Fill Fees Fee pharmacy charges for filling prescription Should not be over $5.00 Often the most important part of fee
    17. 17. 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
    18. 18. 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
    19. 19. Wastage Opened meds cannot legally be reused Source of significant waste
    20. 20. Tips for Reducing Wastage Institute dosage changes after current month’s prescription finishes
    21. 21. Check Pharmacy Bill Mistakescommon $44.77? Or $4.77?
    22. 22. FormularyFormularies are the Community Standard of CareFormularies, properly done, do NOT restrict access to appropriate medicine
    23. 23. 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.
    24. 24. Formulary--Price Should you use Nexium? Or Omeprazole?
    25. 25. Formulary--Convenience Bupropion? Or Bupropion SR?
    26. 26. Formulary—Controlled Drugs Ultram Ambien Soma
    27. 27. Formulary Yes-No $-$$-$$$-$$$$-$$$$$
    28. 28. OTC Commissary Compareaccess to OTC medications in the community with inside corrections
    29. 29. OTC commissary What is the Time Cost to the medical staff of dealing with OTC requests?
    30. 30. OTC Commissary OTC Commissary MUST be cheaper for the inmate than going through sick call.
    31. 31. OTC Commissary OTC Meds inappropriate for corrections Dextromethorphan Ephedrine, pseudoephedrine Ex-Lax
    32. 32. OTC Commissary How to handle Indigency It still may be cheaper to give indigent inmates OTC medications.
    33. 33. OTC Commissary Examples Pain Relievers—Ibuprofen Skin Meds—Antifungal, steroid cream Acne meds—Stridex, Benzoyl Stomache—Ranitidine, omeprazole Constipation—Fiber, colace
    34. 34. OTC Commissary Examples Dietsupplements—Vitamins, lactaid Cold and flu—cough drops, loratidine Eyes—allergy eye drops Psoriasis meds—coal tar
    35. 35. Special Cases Psychiatric Medications May be 40-60% of your total pharmacy bill
    36. 36. 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
    37. 37. Psychiatric Medications Polypharmacy Jailvs outside considerations Fluidity of treatment Drug abuse
    38. 38. HIV Hepatitis C Treatment algorhythm Off-on treatment worse than no treatment at all
    39. 39. Treatment Guidelines Clinical Criteria designed to avoid unnecessary medication prescriptions
    40. 40. CDC RecommendationsPharyngitis Four Clinical Criteria1. Fever2. Exudate3. Lymphadenopathy4. NO cough
    41. 41. CDC RecommendationsSinusitis1. Symptoms for more than 7 days.2. Pain or tenderness of face or teeth3. Purulent nasal discharge.4. Moderate to severe symptoms.
    42. 42. CDC RecommendationsBronchitis No Pneumonia—No Antibiotics1. No Fever2. No tachypnea3. No asymmetric crackles
    43. 43. 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).
    44. 44. 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.
    45. 45. Atypical Antipsychotics vs. TraditionalAntipsychotics Atypical Antipsychotics in the  No difference in symptom Treatment of Schizophrenia: reduction if conventional dose is Systematic Overview and Meta- less than 12mg per day. regression Analysis. Geddes,  Atypicals do cause less extra- J. and Bebbington, P. pyramidal symptoms, but the BMJ 2000; 321: 1371-1376. overall tolerability is identical Meta-analysis of 52 between groups. Randomized trials comparing  “There is no clear evidence that atypical antipsychotics with atypical antipsychotics are more conventional antipsychotics effective or are better tolerated than conventional antipsychotics.”
    46. 46. The Best of the BestInformation Sources1. Primary Care Medical Abstracts2. The Oregon Drug Utilization Review Newsletter3. The Prescriber’s Letter

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