Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics...

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Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels, University of Victoria. [email protected]
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Page 1: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety.

Value of Generics Conference

Montreal, P.Q.

October 26, 2011.

Alan Cassels,

University of Victoria.

[email protected]

Page 2: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

I am Supported by research grants, contracts related to health reporting and a UVIC research salary

Page 3: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

The “learning” objectives:

• Look at some data on current trends in drug spending

• Recount some examples of how people typically receive drugs and drug coverage.

• Suggest ways that drug coverage can become more cost-effective, rationale and safe.

Page 4: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What do we hear from employees regarding drug coverage?

• “If the doctor prescribes it, I must need it and my plan must therefore cover it.”

• “Sure, newer drugs are more expensive, but you get what you pay for, right?

• “My doctor gives me free samples because he cares about my health and the cost of the drugs.”

• “My drugs don’t cost me anything, they’re free. “

Page 5: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Seeking Solutions to the Drug Benefit Cost Crisis*

• Most employer-sponsored drug coverage involves no deductible; most provide 80 to 100% coinsurance.

• More than half of employers have plans with no formulary (open formulary or few formulary restrictions).

• Despite concerns about escalating costs, employers are wearing most of the cost burden.

• Employers are looking for new ways to respond to growing prescription drug costs.

*survey report my group carried out in 2005 of major employers in Canada about trends in drug benefit cost control.

Page 6: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What are some of the ways drug plans control costs?

Change the plan design,

avoid costs or share costs

PLAN DESIGN•Co-insurance •Benefit maximums •Drug formularies •Benefit levels

COST AVOIDANCE•Wellness programs•Absence management•Education/awareness•Legislative shifting•Benefit formulas

COST SHARING•Employee/member contributions•Flex benefits•Health care spending accounts

Page 7: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What are we actually covering?Top Therapeutic Classifications 2009

Avg Cost % Paid by Disease colour

1) Cholesterol disorders $72.60 9.8% GREEN2) Blood pressure $31.66 7.9% PINK3) Diabetes $51.67 6.8%4) Depression $45.69 6.7%5) Ulcers $52.98 6.4% YELLOW6) Rheumatoid Arthritis $1,674.60 5.7%7) Asthma and other Inflammatory Diseases

47.09 5.5%8) Antibiotics/Anti-infectives

$27.56 4.9%9) Narcotic Analgesics $27.28 3.2%10) Skin Disorders $34.10 3.0%

Page 8: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Top 25*RANK NAME SCRIPTS DIN COST PAID COST PER SCRIPT

1 REMICADE INJECTION 12,625 54,759,926 $4,337.422 NEXIUM 40MG TABLET 355,983 34,766,372 $97.663 CRESTOR 10MG TABLET 399,830 34,495,778 $86.284 HUMIRA 40MG/0.8ML PFS INJ 13,533 28,728,311 $2,122.835 ENBREL 50MG INJECTION 12,145 25,471,235 $2,097.266 PLAVIX 75MG TABLET 145,387 18,907,467 $130.057 CRESTOR 20MG TABLET 168,238 18,023,262 $107.138 EZETROL 10MG TABLET 142,409 15,443,547 $108.459 SYMBICORT 200 TURBUHALER 143,506 15,412,380 $107.4010 CELEBREX 200MG CAPSULE 191,909 12,652,487 $65.9311 CIPRALEX 10MG TABLET 139,645 12,356,598 $88.4912 COPAXONE 20MG/ML PFS 7,655 12,255,407 $1,600.9713 CYMBALTA 60MG DR CAPSULE 66,659 11,631,880 $174.50

14 ADVAIR 250UG INHALATION DISKUS 82,897 11,213,330 $135.2715 SINGULAIR 10MG TABLET 80,372 10,332,257 $128.56

16NEULASTA 10MG/ML PFS WITH ULTRASAFE NEEDLE GUARD 3,890 10,316,165 $2,651.97

17 NASONEX AQ. NASAL SPRAY 50MCG 270,974 9,991,909 $36.8718 CRESTOR 5MG TABLET 110,289 9,136,643 $82.84

19 ONE TOUCH ULTRA BLUE TEST STRIP (ON) 77,488 8,790,169 $113.4420 LYRICA 75MG CAPSULE 57,003 8,288,399 $145.4021 SPIRIVA 18MCG CAPSULE 72,619 8,167,883 $112.4822 JANUVIA 100MG TABLET 51,548 8,159,687 $158.2923 AVONEX PS 30MCG/0.5ML SYR 4,099 7,506,267 $1,831.2424 CIPRALEX 20MG TABLET 79,711 7,433,866 $93.2625 LIPITOR 20MG TABLET 71,644 7,205,873 $100.58

* Based on 2009 data from Telus, the pay-direct drug card provider for Sun Life, Great-West Life, Standard Life and other group insurance companies in Canada. The top drugs

represent 10,651,541 prescriptions at a cost of $982,676,747 and an average cost per prescription of $92.25.

Page 9: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Next top 25RANK NAME SCRIPTS DIN COST PAID COST PER SCRIPT

26 REBIF 44MCG (12MIU) PFS 3,523 7,174,368 $2,036.44

27 APO-ATORVASTATIN 20MG TABLET 120,089 7,095,108 $59.0828 LEVEMIR PENFILL 37,657 6,854,048 $182.01

29 TEVA-VENLAFAXINE XR 75MG ER CAPSULE 112,158 6,580,955 $58.68

30 FLOVENT HFA 250MCG INHALER (AEROSOL) 63,547 6,553,955 $103.14

31 ADVAIR 500UG INHALATION DISKUS 33,323 6,538,657 $196.2232 LIPITOR 10MG TABLET 79,872 6,524,926 $81.6933 ADVAIR 250MCG MD INHALER 35,429 6,280,752 $177.2834 BOTOX 50U/100U/200U VIAL 8,654 6,215,217 $718.1935 GLEEVEC 400MG TABLET 1,507 6,099,776 $4,047.63

36 STELARA 45MG/0.5ML INJECTION 1,141 5,871,635 $5,146.0437 DIOVAN 80MG TABLET 77,154 5,676,420 $73.57

38 NOVORAPID 100U/ML INSULIN CARTRIDGE 56,239 5,626,102 $100.0439 MICARDIS 80MG TABLET 76,465 5,549,471 $72.58

40 APO-ATORVASTATIN 10MG TABLET 115,972 5,530,186 $47.6941 CONTOUR TEST STRIP (ON) 48,856 5,488,058 $112.33

42 LANTUS SOLOSTAR 100U/ML PREFILL PEN 5X3ML 37,986 5,427,347 $142.8843 BIAXIN 500MG XL TABLET 103,797 5,391,436 $51.9444 NEUPOGEN 300MCG/ML VIAL 3,577 5,379,047 $1,503.7945 AVAPRO 150MG TABLET 72,976 5,369,313 $73.5846 CRESTOR 40MG TABLET 45,109 5,251,928 $116.4347 COVERSYL 8MG TABLET 71,780 5,236,177 $72.9548 BETASERON 0.3MG VIAL 2,590 5,189,359 $2,003.61

49 PROMETRIUM 100MG CAPSULE 76,357 5,155,094 $67.51

50 FLOVENT HFA 125MCG INHALER (AEROSOL) 99,963 5,072,999 $50.75

51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 $48.34

Page 10: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Sheila’s got heartburn…

• Office Administrator. 34 years old• She has been taking Losec (omeprazole) for

years. It works great.• She feels it’s worth every penny of the $112

per month. Her plan is a 20% deductible so her cost is $22 per month; employer pays $90.

• What’s wrong with this picture?

Page 11: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Sheila’s Story• Has her doctor ever tried her on over-the-

counter treatments for heartburn or “older but proven” H2-antagonists?

• Does she know her benefit plan pays twice as much as it could/should for her heartburn?

• Does she know that PPI users have a higher risk of pneumonia and infection with C-difficile and that long-term use of PPIs is associated with an increased risk of certain bone fractures?

• Many provinces have PPIs under “Special Authority” (prior authorization) so why doesn’t her private drug plan follow?

Page 12: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Proton Pump InhibitorsPPIS

RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

86 LOSEC 20MG SR TABLET 31,342 3,526,819 OMEPRAZOLE MAGNESIUM $112.53

72 PANTOLOC 40MG TABLET 46,986 3,968,654PANTOPRAZOLE SOD SESQUIHYDRATE $84.46

97 PREVACID 30MG CAPSULE 37,861 3,178,019 LANSOPRAZOLE $83.94

139 RATIO-OMEPRAZOLE 20MG SR TABLET 40,657 2,335,652 OMEPRAZOLE MAGNESIUM $57.45

146 MYLAN-OMEPRAZOLE 20MG DR CAPSULE 39,440 2,234,249 OMEPRAZOLE $56.65

55 APO-OMEPRAZOLE 20MG CAPSULE 92,286 4,949,920 OMEPRAZOLE $53.64

110 NOVO-LANSOPRAZOLE 30MG CAPSULE 59,236 2,901,782 LANSOPRAZOLE $48.99

80 APO-PANTOPRAZOLE 40MG TABLET 77,387 3,765,016 PANTOPRAZOLE SODIUM $48.65

51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 LANSOPRAZOLE $48.34

187 SANDOZ PANTOPRAZOLE 40MG TABLET 36,953 1,746,831 PANTOPRAZOLE $47.27

193 TEVA-PANTOPRAZOLE 40MG TABLET 36,358 1,705,965 PANTOPRAZOLE SODIUM $46.92

58 RAN-PANTOPRAZOLE 40MG TABLET 102,136 4,667,691 PANTOPRAZOLE SODIUM $45.70

213 TECTA 40MG EC TABLET 42,947 1,588,876 PANTOPRAZOLE MAGNESIUM $37.00

186 RAN-RABEPRAZOLE 20MG EC TABLET 52,009 1,749,680 RABEPRAZOLE SODIUM $33.64

64 TEVA-RABEPRAZOLE EC 20MG TABLET 137,468 4,336,467 RABEPRAZOLE SODIUM $31.55

937,814 47,719,468 $50.88

Page 13: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Proton Pump InhibitorsPPIS

RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

86 LOSEC 20MG SR TABLET 31,342 3,526,819OMEPRAZOLE MAGNESIUM $112.53

72 PANTOLOC 40MG TABLET 46,986 3,968,654PANTOPRAZOLE SOD SESQUIHYDRATE $84.46

97 PREVACID 30MG CAPSULE 37,861 3,178,019 LANSOPRAZOLE $83.94

139

RATIO-OMEPRAZOLE 20MG SR TABLET 40,657 2,335,652

OMEPRAZOLE MAGNESIUM $57.45

146

MYLAN-OMEPRAZOLE 20MG DR CAPSULE 39,440 2,234,249 OMEPRAZOLE $56.65

55 APO-OMEPRAZOLE 20MG CAPSULE 92,286 4,949,920 OMEPRAZOLE $53.64110 NOVO-LANSOPRAZOLE 30MG CAPSULE 59,236 2,901,782 LANSOPRAZOLE $48.99

80 APO-PANTOPRAZOLE 40MG TABLET 77,387 3,765,016 PANTOPRAZOLE SODIUM $48.65

51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 LANSOPRAZOLE $48.34

187 SANDOZ PANTOPRAZOLE 40MG TABLET 36,953 1,746,831 PANTOPRAZOLE $47.27

193 TEVA-PANTOPRAZOLE 40MG TABLET 36,358 1,705,965 PANTOPRAZOLE SODIUM $46.92

58 RAN-PANTOPRAZOLE 40MG TABLET 102,136 4,667,691 PANTOPRAZOLE SODIUM $45.70

213 TECTA 40MG EC TABLET 42,947 1,588,876 PANTOPRAZOLE MAGNESIUM $37.00

186 RAN-RABEPRAZOLE 20MG EC TABLET 52,009 1,749,680 RABEPRAZOLE SODIUM $33.64

64 TEVA-RABEPRAZOLE EC 20MG TABLET 137,468 4,336,467 RABEPRAZOLE SODIUM $31.55

937,814 47,719,468 $50.88

Page 14: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

PPI Special authority

form, BC

Pharmacare

Page 15: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What is the basis for BC PharmaCare’s “Special Authority” process around PPIs?

• Evidence show that all PPIs are equally effective for the treatment of common acid-reflux conditions.

• PharmaCare’s first-covered PPI for patients eligible for Special Authority approval was previously rabeprazole (Pariet® and generics).

• On January 26, 2010, PharmaCare coverage was expanded for the PPIs, and pantoprazole Mg was added as another first-covered PPI for patients eligible for Special Authority approval. These patients now have two PPI options - rabeprazole and pantoprazole Mg – with one Special Authority approval.

• Patients become eligible after first trying ranitidine (Zantac® and generics), cimetidine (Tagamet® and generics), or a similar drug.

• Excerpts from Pharmacare memo January 26, 2010

Page 16: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Peter has hypertension…

• Retired hospital technician. 74 years old• Told he has “uncontrolled hypertension.” • First drug given to him is a free sample:

Diovan (valsartan)—it’s an ARB• It seems to ‘work’. His municipal pension plan

covers 80% ($60) of its 75$/ month cost. • “My doctor is great. He gave me the best”• What’s wrong with this picture?

Page 17: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Peter’s Story: The reality• Does he know there are many non-drug approaches to

treating hypertension; reduced salt diet, etc?• Does his doctor know that free samples are always the

newest, most expensive, least studied drug? • Does his doctor know the guidelines saying a drug like

Diovan is a 4th line treatment (after a diuretic, an ACE-Inhibitor and maybe a Beta-blocker)?

• Why would his drug plan pay 75$ a month instead of a better treatment costing only $15 per month?

• If his plan was guided by similar rules to BC Pharmacare’s formulary rules he’d need to try an ACE-inhibitor first.

• The Municipal Pension plan got rid of its dental coverage and may dump its drug coverage. Why? It’s unsustainable.

Page 18: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Top drugs for hypertensionRANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

37 DIOVAN 80MG TABLET 77,154 5,676,420 VALSARTAN $73.57

39 MICARDIS 80MG TABLET 76,465 5,549,471 TELMISARTAN $72.58

45 AVAPRO 150MG TABLET 72,976 5,369,313 IRBESARTAN $73.58

47 COVERSYL 8MG TABLET 71,780 5,236,177 PERINDOPRIL ERBUMINE $72.95

56 ATACAND 16MG TABLET 62,464 4,949,782 CANDESARTAN CILEXETIL $79.24

65 DIOVAN 160MG TABLET 55,611 4,297,484 VALSARTAN $77.28

67 COVERSYL 4MG TABLET 83,116 4,143,479 PERINDOPRIL ERBUMINE $49.85

70 AVAPRO 300MG TABLET 54,848 4,044,720 IRBESARTAN $73.74

82 ATACAND 8MG TABLET 52,148 3,717,417 CANDESARTAN CILEXETIL $71.29

85 ATACAND PLUS 16/12.5MG TABLET 47,947 3,591,600 CANDESARTAN CILEXETIL/HCTZ $74.91

90 MICARDIS PLUS 80MG/12.5MG TABLET 49,353 3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE $69.53

93 APO-RAMIPRIL 10MG CAPSULE 90,943 3,280,945 RAMIPRIL $36.08

98 AVALIDE 300MG/12.5MG TABLET 45,785 3,175,360 IRBESARTAN/HCTZ $69.35

99 DIOVAN-HCT 160/12.5MG TABLET 44,245 3,171,984 VALSARTAN/HCTZ $71.69

111 COZAAR 50MG TABLET 33,517 2,798,256 LOSARTAN POTASSIUM $83.49

127 DIOVAN-HCT 160MG/25MG TABLET 35,047 2,562,292 VALSARTAN/HCTZ $73.11

130 COVERSYL PLUS 4MG/1.25MG TABLET 37,216 2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE $67.44

151 COZAAR 100MG TABLET 27,196 2,188,671 LOSARTAN POTASSIUM $80.48

155 TEVA-RAMIPRIL 10MG CAPSULE 55,150 2,150,252 RAMIPRIL $38.99

160 AVALIDE 150MG/12.5MG TABLET 29,351 2,074,953 IRBESARTAN/HCTZ $70.69

170 HYZAAR DS (100MG/25MG) TABLET 27,558 1,984,045 LOSARTAN POTASSIUM/HCTZ $72.00

178 DIOVAN-HCT 80/12.5MG TABLET 27,066 1,881,902 VALSARTAN/HCTZ $69.53

190 AVALIDE 300MG/25MG TABLET 25,264 1,717,448 IRBESARTAN/HCTZ $67.98

191 RAN-RAMIPRIL 10MG CAPSULE 35,952 1,707,648 RAMIPRIL $47.50

219 APO-RAMIPRIL 5MG CAPSULE 59,613 1,514,414 RAMIPRIL $25.40

222 MICARDIS 40MG TABLET 22,540 1,499,432 TELMISARTAN $66.52

1,300,305 84,224,985 $64.77

Page 19: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Top drugs for hypertensionRANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

37 DIOVAN 80MG TABLET 77,154 5,676,420VALSARTAN $73.5739 MICARDIS 80MG TABLET 76,465 5,549,471 TELMISARTAN $72.58

45 AVAPRO 150MG TABLET 72,976 5,369,313 IRBESARTAN $73.58

47 COVERSYL 8MG TABLET 71,780 5,236,177 PERINDOPRIL ERBUMINE $72.95

56 ATACAND 16MG TABLET 62,464 4,949,782 CANDESARTAN CILEXETIL $79.24

65 DIOVAN 160MG TABLET 55,611 4,297,484 VALSARTAN $77.28

67 COVERSYL 4MG TABLET 83,116 4,143,479 PERINDOPRIL ERBUMINE $49.85

70 AVAPRO 300MG TABLET 54,848 4,044,720 IRBESARTAN $73.74

82 ATACAND 8MG TABLET 52,148 3,717,417 CANDESARTAN CILEXETIL $71.29

85 ATACAND PLUS 16/12.5MG TABLET 47,947 3,591,600 CANDESARTAN CILEXETIL/HCTZ $74.91

90 MICARDIS PLUS 80MG/12.5MG TABLET 49,353 3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE $69.53

93 APO-RAMIPRIL 10MG CAPSULE 90,943 3,280,945 RAMIPRIL $36.08

98 AVALIDE 300MG/12.5MG TABLET 45,785 3,175,360 IRBESARTAN/HCTZ $69.35

99 DIOVAN-HCT 160/12.5MG TABLET 44,245 3,171,984 VALSARTAN/HCTZ $71.69

111 COZAAR 50MG TABLET 33,517 2,798,256 LOSARTAN POTASSIUM $83.49

127 DIOVAN-HCT 160MG/25MG TABLET 35,047 2,562,292 VALSARTAN/HCTZ $73.11

130 COVERSYL PLUS 4MG/1.25MG TABLET 37,216 2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE $67.44

151 COZAAR 100MG TABLET 27,196 2,188,671 LOSARTAN POTASSIUM $80.48

155

TEVA-RAMIPRIL 10MG CAPSULE 55,150 2,150,252RAMIPRIL $38.99

160 AVALIDE 150MG/12.5MG TABLET 29,351 2,074,953 IRBESARTAN/HCTZ $70.69

170 HYZAAR DS (100MG/25MG) TABLET 27,558 1,984,045 LOSARTAN POTASSIUM/HCTZ $72.00

178 DIOVAN-HCT 80/12.5MG TABLET 27,066 1,881,902 VALSARTAN/HCTZ $69.53

190 AVALIDE 300MG/25MG TABLET 25,264 1,717,448 IRBESARTAN/HCTZ $67.98

191

RAN-RAMIPRIL 10MG CAPSULE 35,952 1,707,648RAMIPRIL $47.50

219

APO-RAMIPRIL 5MG CAPSULE 59,613 1,514,414RAMIPRIL $25.40

222 MICARDIS 40MG TABLET 22,540 1,499,432 TELMISARTAN $66.52

1,300,305 84,224,985 $64.77

Page 20: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Savings if you covered blood pressure pills according to the guidelines?

What if the most effective, guideline-approved drug was the one prescribed first?

– Diovan: 77,000 prescriptions, total cost $5.6 million.– Generic ramipril: $43 per script would cost $3.3 million– Generic hydrocholorothiazide: $2.45 per script would cost $188,000

Page 21: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Marge has ‘high’ cholesterol• University sociologist: 54 years old• Told she has “high cholesterol”. • She asks for a generic; gets generic atorvastatin.• It costs 50% of the brand ($50 instead of $100)• Needs a ‘boost’ so her doctor gives her a sample

of Ezetrol (ezetimibe)$108/ month • “My doctor is great. He really cares about

bringing my cholesterol down.”• What’s wrong with this picture?

Page 22: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Marge’s Story

• Treating “high cholesterol” in women is unproven.

• A study released in January 2008 showed ezetimibe had no benefit on the buildup of arterial plaque when compared with patients taking only statins. $108 for no added benefit?

• Side effects include: Rhabdomyolysis - severe muscle damage including pain, tenderness, weakness and liver damage.

• Marge wonders why she feels weak all the time.

Page 23: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Statins: drugs to lower cholesterol

RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

46 CRESTOR 40MG TABLET 45,109 5,251,928 ROSUVASTATIN CALCIUM $116.43

8 EZETROL 10MG TABLET 142,409 15,443,547 EZETIMIBE $108.45

7 CRESTOR 20MG TABLET 168,238 18,023,262 ROSUVASTATIN CALCIUM $107.13

66 LIPITOR 40MG TABLET 40,018 4,209,578 ATORVASTATIN CALCIUM $105.19

25 LIPITOR 20MG TABLET 71,644 7,205,873 ATORVASTATIN CALCIUM $100.58

232 LIPITOR 80MG TABLET 14,515 1,422,804 ATORVASTATIN CALCIUM $98.02

3 CRESTOR 10MG TABLET 399,830 34,495,778 ROSUVASTATIN CALCIUM $86.28

18 CRESTOR 5MG TABLET 110,289 9,136,643 ROSUVASTATIN CALCIUM $82.84

32 LIPITOR 10MG TABLET 79,872 6,524,926 ATORVASTATIN CALCIUM $81.69

154 LIPIDIL EZ 145MG TABLET 34,986 2,160,978 FENOFIBRATE $61.77

63 APO-ATORVASTATIN 40MG TABLET 73,671 4,383,327 ATORVASTATIN CALCIUM $59.50

27 APO-ATORVASTATIN 20MG TABLET 120,089 7,095,108 ATORVASTATIN CALCIUM $59.08

246 APO-ATORVASTATIN 80MG TABLET 23,730 1,351,439 ATORVASTATIN CALCIUM $56.95

40 APO-ATORVASTATIN 10MG TABLET 115,972 5,530,186 ATORVASTATIN CALCIUM $47.69

1,440,372 122,235,377 $84.86

Page 24: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Statins: drugs to lower cholesterol

RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT

46 CRESTOR 40MG TABLET 45,109 5,251,928 ROSUVASTATIN CALCIUM $116.43

8 EZETROL 10MG TABLET 142,409 15,443,547 EZETIMIBE $108.457 CRESTOR 20MG TABLET 168,238 18,023,262 ROSUVASTATIN CALCIUM $107.13

66 LIPITOR 40MG TABLET 40,018 4,209,578 ATORVASTATIN CALCIUM $105.19

25 LIPITOR 20MG TABLET 71,644 7,205,873 ATORVASTATIN CALCIUM $100.58

232 LIPITOR 80MG TABLET 14,515 1,422,804 ATORVASTATIN CALCIUM $98.02

3 CRESTOR 10MG TABLET 399,830 34,495,778 ROSUVASTATIN CALCIUM $86.28

18 CRESTOR 5MG TABLET 110,289 9,136,643 ROSUVASTATIN CALCIUM $82.84

32 LIPITOR 10MG TABLET 79,872 6,524,926 ATORVASTATIN CALCIUM $81.69

154 LIPIDIL EZ 145MG TABLET 34,986 2,160,978 FENOFIBRATE $61.77

63 APO-ATORVASTATIN 40MG TABLET 73,671 4,383,327 ATORVASTATIN CALCIUM $59.50

27 APO-ATORVASTATIN 20MG TABLET 120,089 7,095,108 ATORVASTATIN CALCIUM $59.08

246

APO-ATORVASTATIN 80MG TABLET 23,730 1,351,439 ATORVASTATIN CALCIUM $56.95

40 APO-ATORVASTATIN 10MG TABLET 115,972 5,530,186 ATORVASTATIN CALCIUM $47.69

1,440,372 122,235,377 $84.86

Page 25: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What values would a “Values-based” formulary be based on?

• Full access to the “best” medications.• Best?

– NEWEST

– MOST COSTLY

– MOST ADVERTISED

– MOST SEXY

– MOST ADVANCED

– MOST TALKED ABOUT

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Page 26: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What values would a “Values-based” formulary be based on?

• Full access to the “best” medications.• Best?

– Best in effectiveness

– Best in cost effectiveness

– Best in safety

– Best in terms of a proven track record (no surprises)

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Page 27: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What these stories tell us?

• Free samples are gateway drugs to higher drug spending and poor prescribing.

• Private drug plans who “pay for everything” often disregard the concept of comparative cost effectiveness. Employees and employers suffer.

• Both employees and employers should avoid a drug plan that provides automatic coverage of:• More expensive drugs vs. less expensive drugs that are

equally effective.• Brand names vs. generic drugs which do the same thing.• Newer drugs of unknown benefit vs. older proven

therapies.• Drugs of questionable safety vs. drugs whose safety

profile we know.

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Page 28: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

“Managing” the formulary.

• Needs an independent, high quality source of drug information for payers, patients and prescribers.

• Three key elements: prior authorization, generic substitution and therapeutic substitution.

• Involves other costs, especially education and communications.

• Employees need to be incented to seek value in their prescriptions. “They don’t cost anything, they’re free!”

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Page 29: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

What role do plan sponsors have in educating their members who believe?:

• “If the doctor prescribes it, I must need it and my plan must pay for it.”

• “Newer drugs are more expensive, but they are always going to be better. You pay for what you get, right?”

• “The drugs don’t cost me anything, they’re free.“

Page 30: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

Conclusions

• ‘Newer’ never automatically mean ‘more effective.’

• Communicating ‘value for money’ to payers, patients and prescribers would help improve rational use of drugs.

• Think of drug coverage in terms of “What is it that we value?”

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Page 31: Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels,

How to contact me:

Alan Cassels University of Victoria

[email protected] 361 3120