eJournal

By Josephine C. Babiarz, Esq.; Timothy R. Hudd, PharmD, R.Ph, AE-C; and Erica Barry, PharmD Candidate, 2017 ¹

(This is a preview of a Section Review article, which will be featured in the December 2014 issue of Massachusetts Lawyers Journal.)

Based on results from the CMS Government Medicare Plan D evaluator tool, prescription drug costs for identical prescriptions varied more than $10,700 between available plans. Estimated costs for a patient's drug plan insurance premium and drug costs ranged from $3,474 to $14,221 for 2015. Additionally, mail order prescription fulfillment was the most expensive option in all but one of the plans.   

This article details our findings, explains the operation of the Medicare Plan D Finder website, and provides general guidance on the advice patients should seek from pharmacists regarding drug regimens and drug costs which may impact drug adherence.

The open enrollment period for Medicare Part D began on October 15, 2014 and extends until December 7. We used the Medicare Plan Finder for Part D² to evaluate our plans. The drug list consists of six of the top 10 most-prescribed drugs, based on data collected from July 2013 - June 2014 ³. It is not uncommon for Medicare patients to take six or more prescriptions and since costs increase with the number of drugs, the selection of an appropriate insurance plan becomes essential. The selected drugs cover common conditions:

1. High cholesterol/triglycerides (Crestor Tab 40mg)
2. High blood pressure/heart failure (Diovan Tab 160 mg)
3. Pain, depression and anxiety (Duloxetine HCL Cap 60 mg)
4. Thyroid replacement therapy (Levothyroxine Sodium Tab 100 mcg)
5. Nerve pain and fibromyalgia (Lyrica Cap 75 mg)
6. Heartburn, GERD (Nexium Cap 20 mg)⁴

The Part D plan evaluation begins with the selection of a zip code. We located our study in a Boston suburb, with a large number of pharmacies relative to its size. The finder next requests that the beneficiary select a pharmacy (a "preferred pharmacy"). We determined that pharmacy selection influences price, and consequently we ran the plan evaluator separately for each participating pharmacy we chose. While it is possible to select more than one preferred pharmacy when we did select two, the plan gave the lowest price plan for only one of the pharmacies. In other words, the results for the second pharmacy were not reported, so we did not have a valid comparison until we ran the evaluator for each pharmacy independently.

We selected the category "Lowest Estimated Annual Retail Drug Cost" in the evaluator, and then selected "all plans" for results. We studied four separate preferred pharmacies, including a national retail chain, a community pharmacy and a pharmacy located in a retail setting. Because actual results vary by drug list, zip code and pharmacy, we report only de-identified information. Cost calculations include insurance premiums and deductibles, if any, as well as the cost for drugs which were not covered by insurance.

The data we collected is detailed in Figure 1:



There are caveats in using the evaluator. First, all of the drug costs listed are estimated; actual drug prices may vary throughout the year. This variation may not impact patients, if the drug plan uses co-pays which are fixed amounts and not co-insurance where patients pay percentages of drug cost. More importantly, an insurance company is not required to cover the drug throughout the insurance year; a drug can be removed from coverage (that is, removed from the formulary) with 60 days' notice to a patient. This typically gives the patient one last covered refill and a higher cost for subsequent refills. Lastly, a patient may not need a particular drug for 12 months, or may be switched to a different drug to address a condition.

This cost analysis did not include any rewards card or loyalty programs which may be offered by retail pharmacies, nor does it include any financial assistance, such as pharmaceutical assistance programs (For example, see Figure 2 for the description of the pharmaceutical assistance available for Crestor).

The plan evaluator includes a cost reduction feature that alerts patients if a generic drug or a therapeutic equivalent is available. For example, Nexium is a Tier 4 (high cost brand-name drug), with an estimated annual cost of $3,410. The evaluator suggests three lower cost alternatives to Nexium: Dexilant (Tier 3, brand-name) at $3,264/annual, omeprazole (Tier 1, preferred generic) at $3,280/annual and pantoprazole (Tier 2, generic) at $3,285/annual. After revising the drug list to remove Nexium and include omeprazole, the evaluator generated a different insurance plan as having the lowest annual cost. The total cost for the plan with omeprazole is $3,267, the lowest annual cost result we obtained for retail pharmacy and the mail order option was the lowest price, of all options, at $3,202. With a prescription, the Medicare Part D patient cost for a year's supply of omeprazole is about $45.00. However, omeprazole is available Over-The-Counter (OTC) without prescription, at a cost of about $200 per year. One important question for the healthcare professional is whether a 12-month regimen of any of these heartburn medications is appropriate. According to the OTC package labeling, omeprazole should not be used for more than the recommended treatment period of 14 days. Patients should contact their physician if the product is still needed after the 14-day course, or if more than one course of treatment is needed more than every four months⁵.

Patients should never make therapeutic decisions without first consulting a medical professional about the drugs prescribed, despite the suggestions from the evaluator. Pharmacists are well-qualified to provide information essential to the patient for Medicare Part D evaluation. However, a pharmacist may not promote a particular insurance plan to a patient.

The first step in using the evaluator is to obtain from your pharmacist a drug list which correctly identifies the prescription medications and dosing. Under the HIPAA regulations, 45 CFR § 164.524 and § 164.510(b), patients have "a right to access, to inspect and obtain a copy of protected health information about the individual in a designated record set" with few exceptions. Pharmacists are permitted to disclose information to family members or other individuals responsible for the care of the patient so long as the patient does not object to the pharmacy sharing the information with that person. Also, a pharmacy must provide a print-out of the patient's prescription drug spending, for tax records at any time. These records should provide accurate spelling and dosing for the drugs, which makes using the evaluator feasible for non-medical personnel.

Additionally, a pharmacist is required by Massachusetts regulations to both conduct a "Drug Utilization Review (DUR)" and to discuss issues that "in the pharmacist's professional judgment, are deemed to be significant for the health and safety of the patient" 247 CMR § 9.07. To paraphrase the regulation, a DUR may include a review of the patient record and each new prescription presented for dispensing, for the purpose of promoting therapeutic appropriateness, by making a reasonable effort to identify the following:

over-utilization or under-utilization; therapeutic duplication; drug-disease contraindication; drug-drug interaction; incorrect drug dosage or duration of drug treatment; drug-allergy interactions; clinical abuse or misuse; and any significant change in drug, dose or directions. When the pharmacist determines any of the foregoing, the pharmacist shall take appropriate measures to ensure the proper care of the patient which may include consultation with the prescribing practitioner and/or direct consultation with the patient.

To illustrate the value of a pharmacist's drug utilization review, we present a fictional example. A 67-year-old female presents to the pharmacy on several prescription medications. She has been seen by three specialists over the past year, in addition to her primary care physician with whom she visits regularly. She doesn't understand why she is taking so many medications and is displeased with the associated financial burden. Brand name copays appear to be a significant contributing factor to the overall cost of the regimen. After thoroughly reviewing the list of medications, the pharmacist notes the patient is taking brand name Crestor five mg daily for high cholesterol. Crestor belongs to a class of medications known as "statins". Although this agent is not available generically, there are alternative agents within the statin class that may be considered. However, several important questions should be answered before providing a patient recommendation. Is the medication necessary? Will the medication be needed chronically? If the response to these questions is "yes" the next step is to assess whether or not the patient has been consistently taking the prescribed medication. If so, what has been the response? The pharmacist will also run an interaction check to determine whether the medication interacts with other medications prescribed. The interaction check should then be replicated using the proposed alternative as well. Finally, it is important to determine whether other medications have been used for the same indication in the past. If so, what was the patient response? We have not been given enough information in this example to responsibly recommend an alternative therapy. However, this example illustrates the level of training and expertise necessary to ensure any changes to a regimen are done safely as well as the potential harm in selecting a therapeutic alternative suggested by the Plan Evaluator. We note that substitution of a generic drug for a brand name drug is generally required and is not considered a "therapeutic alternative."

We close with some suggestions on actually using the evaluator plan. For our study, we did not enroll a patient. Because of the significant price differences, we recommend first-time users explore the website, without entering a SSN. After entering the drug list, save the list and record the site-generated number and date. This will save considerable time going forward. Finally, inexperienced users can spend between eight to 10 hours duplicating our studies. With practice and a saved drug list, we were able to reduce the time to less than two hours.

In conclusion, our pilot study demonstrates that the Medicare Part D plan finder is an effective tool in determining a patient's cost of prescription drugs. The plan finder not only estimates insurance costs, but also suggests drugs to switch in order to save money. However, a Drug Utilization Review by a pharmacist or other health care professional is necessary before a patient should consider changing one drug for another.

Click here for a graph with information about the pharmaceutical companies assistance program for Crestor.

¹ The authors thank David Johnson, executive vice-president, Massachusetts Pharmacists Association.
² Found at www.Medicare.gov/find-a-plan/questions/home.aspx.
³ Drug list from www.webmd.com/new/20140805/top-10-drugs.
⁴ The authors note that this list reflects a total number of prescriptions drugs higher than that taken by the average Medicare patient, but also that the number of drugs prescribed per patient is inconsistent throughout the country (see Prescription Drug Use Among Medicare Patients Highly Inconsistent, accessed at http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/10/prescription-drug-use-among-medicare-patients-highly-inconsisten.html). This list is reflective of conditions suffered by a substantial number of Medicare patients.
⁵ Product Information: PRILOSEC OTC(R) -- omeprazole magnesium delayed release tablets. Procter & Gamble, Cincinnati, OH.