Biotechnology Healthcare - November/December 2008 - (Page 47) “Does there come a point in time when one has to start restricting the benefit?” Czekanski asks. “We’ve been able to work around it. But it worries me.” at a certain point you’re limited in the additional things you can do. So, if the average cost of a prescription is up 5 percent, it’s because manufacturers are raising the wholesale cost.” In addition to its own regular number-crunching sessions to stay on top of the budgeting process, GIC representatives routinely sit down with executives from Express Scripts to review how they are doing. “We depend on Express Scripts and CuraScript,” says Czekanski. “They have the physicians. They have the pharmacists. They are the people who are developing the criteria for all of our medications, and not just specialty medications. They develop the criteria for appropriate use and prior authorization. We have to make sure human growth hormone isn’t being used inappropriately. We only pay for those drugs when there’s an appropriate medical need.” GETTING EXPERT HELP One of the toughest challenges the state faces is controlling the cost of biologics. “There don’t tend to be a lot of alternatives for biologics,” says Czekanski. “We have been looking at it; they are very expensive. Specialty drugs account for 14 percent of total drug spending. The average cost of all prescriptions is $62; the average cost of specialty drugs is $1,673.” To Czekanski, the best kind of program for any payer isn’t available. Lawmakers could make payers’ jobs a lot easier, he says, if they were to establish a regulatory pathway to approve biologic follow-ons. In the meantime, the state isn’t helpless. “Express Scripts has CuraScript, their specialty pharmacy,” says Czekanski. “CuraScript provides the drugs to members by mail. They also do a lot of patient counseling and follow-ups, along with calls to remind them that it is time to fill their prescription. “CuraScript had been an optional service,” he continues. “Members had a choice: Fill the prescription at the regular pharmacy or go to CuraScript.” But given the expense of biologics, GIC wanted to ensure that those members who needed them were getting the most out of them. “The potential for waste is enormous. We want people to use those medications and we want to make sure they’re using them appropriately and that they stay on them. Hepatitis C drugs can make you ill. We don’t want people taking them and then stopping. So in July 2007, we said that if you have a specialty medication, you have to get it from CuraScript.” The idea he says, was not to restrict access to specialty drugs. “We just thought it was a much better service for the members. And we lowered the copayment on those medications. They have to pay only $10 a month, which is less than the $20 copayment for brand drugs. We do not want to create any kind of disincentive to get those medications.” When GIC instituted the requirement, Czekanski was prepared to hear from members who didn’t like the new rule. “That did happen a bit, but not to the extent we thought it would. There were some complaints we had to address, but not a large number, and it’s gone very well.” A DOSE OF REALITY But Czekanski also can see a day coming when rising drug costs and limited budgets may collide. “The cost of the specialty medications is a great concern to us, and one always worries,” he says. “States are in financial distress. Does there come a point in time when one has to start restricting the benefit to stay in the budget? We’ve been able to work around it. But it worries me.” It’s particularly worrisome to Czekanski that benefit management trends these days all point to cost shifting. “I don’t think we would do anything [like that] particularly aimed at specialty medications,” notes Czekanski. “A copayment increase would be across the board. People using specialty medicines are just like every one of our members. They need help. I find it disturbing that some employers have 10 or 20 percent coinsurance. That’s penalizing people who are really sick. These medications are very expensive and these people aren’t haphazardly deciding to take them. With the path that employers are taking” — cost shifting — “the result is people don’t take their medications.” John Carroll is a freelance writer and is the editor of Fierce Biotech. Employer to Employer A regular column for healthcare purchasers Case studies of how employers, coalitions, and other purchasers approach the challenges of managing biologics. Send your story to Mike Dalzell, editor, at mdalzell@medimedia.com. NOVEMBER/DECEMBER 2008 · BIOTECHNOLOGY HEALTHCARE 47
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