Transcript Pharmacy Benefits and Programs A true area of excellence for Blue Cross and Blue Shield of Florida.

Pharmacy Benefits and Programs
A true area of excellence for
Blue Cross and Blue Shield of Florida
Pharmacy Management
Strategy
Ensure customer access to
safe and clinically effective
medication that improves
health care outcomes while
maintaining affordability.
• Goals
• Meet employer/customer expectations regarding
understanding of prescription drug utilization,
market and cost trends and pharmacy benefits
• Optimize the quality of pharmaceutical care
• Develop programs to positively impact Rx utilization and total medical
cost
• Promote understanding of medication effects, safety, appropriate use and
the value of adherence to treatment regimens
• Cover medications that offer optimization of health outcomes and
represent the best overall value for members
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Utilization Management
Programs
• Utilization management programs use clinical
criteria and best practices to control member
over and under utilization
• Through combining medical and pharmacy claim
data, this program delivers more accurate
targeting, higher provider and member
satisfaction, and better quality of care outcomes
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Responsible Steps
• Program details
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Promote safe and effective use of medications
Reduce inappropriate use of medications
Increase member savings
BCBSF’s clinical step-therapy program
• Requires trial of one or more alternative medications before
coverage of a targeted drug
• Only certain medications included; selection based upon sound
clinical quality and safety data that justify inclusion in program
• Targeted Drug Class: Cox-II Inhibitors (Celebrex),
Byetta, Insomnia Agents, Atopic Dermatitis, Statins
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Responsible Dose – Medication
Dosing and Compliance Initiative
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FACTS
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GOAL
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Change prescriptions written for multiple daily doses to
single daily dose
ACTION
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Many prescriptions are written for two doses of a lower
strength to be taken daily
These medications are available in one tablet dose
prescription
One tablet dosage = less cost for BCBSF and more
convenience for the member
Targeted mailings to ask physician to consider a change to
once-a-day doses or requests member to talk to their
physicians
RESULTS
45% of physicians approve
dosage changes
$34 average net savings per
Rx changed
OUTCOMES
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Enhanced member convenience and improved adherence
Reduced potential benefit abuse (>31 tablets for one copay)
Reduced Rx costs
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Responsible Quantity – Coverage
Maximum Initiative
• Quality initiative with a focus on a maximum
recommended dose of specific medications
based on dosing guidelines established by the
manufacturer and FDA
• Includes a monthly coverage maximum based
on the recommended dosage and duration of
therapy
• Valuable information provided to the
prescribers and member-patient to make
appropriate medical condition therapy
choices
• Results of the initiative were nationally
recognized in a peer-reviewed pharmacy
publication
EXAMPLE
SAVINGS
(with one drug category –
migraine
medications)
$8.44 PMPM
enrolled migraine
member
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Copay Waiver Program
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Patients taking any of the brand medications listed in the program may speak with their
physician, and if ok can switch to the generic or over the counter medication. BCBSF will then
initiate a one time waiver of the first copay(retail or mail order).
Value: For every 1% increase in generic dispensing rate there is an approximate 1% decrease in drug spend
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BCBSF Generic Initiatives
• Benefit Design
– Generics Lowest Member Cost
Share
– Formulary Design
• Clinical Programs
– Copay Waiver
• Member and Provider
Communications
• Medication Therapy Management
Programs
– Step Therapy
– Prior Authorizations
– Responsible RX
• Web Tools
– Cost comparisons
– Preferred Medication List
– Florida Blue Publication
www.bcbsfl.com
– BlueLine
www.bcbsfl.com
– Member Mailings
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Specialty Pharmacy Management
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Program Goals
– Simplify the physicians/members acquisition of injectable drugs for improved member
access
– Streamline the process for submission of claims for injectable drugs to enable trend
management
– Promote safety through utilization management initiatives
– Provide a cost-effective, quality service for members
BlueOptions and BlueChoice
Injectable Medication
Program Suppliers
CVS/Caremark
Physician-administered
medications covered by
Medical benefit
Self-administered
medications covered by
Prior Authorization
Requirement
(800) 955-5692
Medical benefit
Pharmacy benefit (on-line claim processing)
Medical benefit: No
Pharmacy benefit: Yes
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BCBSF Injectable Program
• Provider and Member Access
– Specialty Rx-Fully Array of Solutions
• CVS/Caremark
• Dedicated Hemophilia Provider: Accredo
• Plus Retail Pharmacy Network
• Provider Office & Home Delivery through
Injectable Drug Supplier (IDS) and BlueOptions
Drug Supplier (BOIDS) network
• Drug Replacement available to providers
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Cost Containment: Pharmacy Programs
Incentive Based Formulary
Managed by Pharmacy & Therapeutics Committee and is comprised of
practicing physicians and pharmacists.
Dose Optimization Program
BCBSF Drug Dosing Initiative exists in order to provide you information
that may help improve compliance to long-term medicines.
RESPONSIBLE RX
Responsible Quantity
(coverage maximum program)
Copay Waiver Program
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A limited list of medications have a maximum quantity for which
coverage will be allowed for one month.
The maximum quantity covered is based on FDA and the
manufacturer’s dosing recommendations
Members who have been taking certain brand-name medications and
switch to a generic or over the counter medication can have their first
prescription copay waived! That is, the member can try a generic for
FREE! (ASO group approval required)
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Cost Containment: Pharmacy Programs
Prior Authorization
Appropriate Antibiotic
Prescribing
Medication Withdrawal –
Recall Notification
Program
BCBSF has Prior Authorization processes in place for certain specified self-administered injectables when a physician
or member desires to obtain those medications via the member’s pharmacy benefit rather than under their health
coverage benefit.
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Appropriate antibiotic prescribing is promoted through provider educational initiatives and member mailings.
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When medicine safety data becomes available, we strive to provide physicians information that may be
helpful. We watch for “news” items, pharmacy literature and medical literature about all medication safety
issues to assist our members and their prescribers.
In addition, in each publication of our member newsletter we include a column dedicated to medication
safety and provide tips to our members about how to "stay safe" with medication therapies.
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RESPONSIBLE RX
Step Therapy
Poly-Pharmacy
Tablet Splitting
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The application of on-line step therapy edits is used to ensure appropriate use of preferred first line
medication treatment options prior to second line drug medication and the promotion of generic medication
options being utilized.
The step therapy program will be implemented as an electronic prior authorization process that occurs at the
time a pharmacy submits a prescription claim electronically.
A new voluntary Commercial Poly-pharmacy Program, which encourages members with multiple chronic medications
to review their medications and supplements with their doctor began in October 2007. The program targets
members in commercial plans who are taking five or more chronic medications for three consecutive months,
prescribed by more than one physician. Members matching the criteria, identified by claims data, are at higher risk
for adverse effects, drug interactions and non-compliance.
A new voluntary program for targeted members of our group commercial products with a co-insurance benefit
design taking a select list of medications. This program allows them to take their dose of medication in a half-tablet
rather than a whole tablet. Participating members will save half of their coinsurance. The start date of this program
was Jan. 1, 2008.
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Cost Containment: Prior Authorization for
Self-Administered Injectable Drugs
The following self-administered injectables require authorization when a physician or member desires to obtain
those medications via the member’s pharmacy benefit rather than through health benefits.
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Actimmune
Aranesp PA
Arixtra PA
Avonex
Betaseron
Calcijex (calcitriol) 1 mcg/mL
Calcijex 2 mcg/mL
Copaxone
DDAVP (desmopressin) 4 mcg/mL
D.H.E. 45 (dihydroergotamine)
Eligard PA
Enbrel PA
EpiPen
EpiPen Jr
Epogen PA
Forteo PA
Fragmin PA
Fuzeon
Genotropin PA
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Note: For our BlueSelect product, the following drugs also require authorization: Zyvox, Actiq, Fentora and oral Fentanlyl.
Geref PA
Glucagon Emergency Kit
Humatrope PA
Humira PA
Imitrex
Increlex PA
Innohep
Intron A PA
Iplex PA
Kineret PA
Leukine PA
Lovenox PA
Lupron (leuprolide) PA
Lupron Depot PA
methotrexate
Miacalcin
Neulasta PA
Neumega PA
Neupogen PA
Norditropin PA
Nutropin PA
Nutropin AQ PA
Omnitrope PA
Pegasys PA
Peg-Intron PA
Procrit PA
Prostigmin
Raptiva PA
Rebif
Roferon-A PA
Saizen PA
Sandostatin (octreotide)
Serostim PA
Somavert
Tev-Tropin PA
Vidaza PA
Zorbtive PA
As of October 2008
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MyRxHealth
Member’s Personal,
Online Pharmacy Portal
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Access through MyBlueServiceSM Capabilities
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* Provided through Prime Therapeutics LLC®
Provides up to one year Pharmacy Claims &
Expense History
Pharmacy Locator with Map Quest
Formulary Search
Provides Alphabetical and Therapeutic
Medication Guide Listings
Supplies Medication Costs
Offers information on savings through use of
generic medications
Provides access to:
• Drug Information
– drug-drug interactions
– drug-food interactions
– Side effects & precautions
• Mail order
– Refills
– Order status
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We’re Committed to Listening and
Providing Caring Solutions
• Our mission as a strategic partner of the colleges is to
customize your plan designs for ultimate flexibility and plan
options that meets the individual needs of each college.
• Our strategies include pricing to reflect your colleges’
experience while taking advantage of pooling though the
Consortium.
• A focused approach and support in facilitating your wellness
program.
• THANK YOU for the trust and confidence you place in us in
meeting the needs of your college.
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Thanks for the opportunity to serve you!
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