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State of the DoD Pharmacy Benefit Process & Implementation

State of the DoD Pharmacy Benefit Process & Implementation. David Bretzke, PharmD Shana Trice, PharmD. Objectives. Describe the DoD P&T process Describe and discuss recent Uniform Formulary decisions and their impact on MTFs

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State of the DoD Pharmacy Benefit Process & Implementation

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  1. State of the DoD Pharmacy BenefitProcess & Implementation David Bretzke, PharmD Shana Trice, PharmD

  2. Objectives • Describe the DoD P&T process • Describe and discuss recent Uniform Formulary decisions and their impact on MTFs • Describe resources available to MTFs to support local Uniform Formulary implementation plans

  3. DoD P&T Committee Beneficiary Advisory Panel PEC Clinical Operations Pharmacy Operations Center Services MTF Commander P&T Committee Providers Pharmacies Director, TMA TMA Pharmacy Program Office TMA Contracting / DSCP TRICARE Contracts Express Scripts (TMOP, TRRX support staff) Medical Patients (beneficiaries) Pharmaceutical Industry DoD Formulary Management Players

  4. Uniform Formulary Decision Cycle • Preliminary review (T-180) • P&T Committee meets (T-90) • Defines class, BCF or ECF • Request for Pricing Info (T-75) • Price Quotes Received (T-20) • P&T Committee meets (T) • Final review, recommendations • BAP meets (T+45) • Comments to TMA • TMA Director reviews & signs minutes (T+60) • Implementation of decisions (no later than T+240) 90-Day Decision Cycle

  5. Everything Happens at Once… whimper May063 Classes

  6. Drug Class Review Process • Defined in UF Final Rule • Clinical Effectiveness • Cost Effectiveness • Takes into consideration usefulness across entire MHS • Formulary Management Tools • 3rd tier (NF at MTF, $22 at Mail & Retail) • Prior Authorization • Quantity Limits • BCF / ECF

  7. Clinical Effectiveness • How a drug compares within its class • Extensive review of evidence • Overall clinical utility or usefulness • Safety, tolerability, efficacy/effectiveness • Provider opinion • Clinical coverage • Therapeutic interchangeability • How many do you need?

  8. Cost Effectiveness • Cost across MTFs, Mail Order & Retail Network • Pharmacoeconomic analysis • Primarily cost effectiveness analyses • Weigh cost and clinical attributes of individual medications • Sensitivity analyses to account for variability • Budget impact analysis • Market share migration • Cost of Medical Necessity determinations • Copay differences • Switch costs • How much are you willing to pay?

  9. Uniform Formulary Recommendations  Cost • Balance clinical and cost effectiveness = formulary status • Non-formulary drugs less clinically and/or less cost-effective • Value judgment • MTFs part of overall system More Costly, More Effective More Costly, Less Effective Maybe No NW NE Effectiveness SW SE Less Costly, Less Effective Less Costly, More Effective Maybe Yes The Cost Effectiveness Plane

  10. Implementing the Uniform Formulary • One class at a time • Not ‘on’ UF until class reviewed • New FDA-approved drugs • May prompt UF review • If class already reviewed, compared to least clinically or cost effective UF drug • BCF/ECF • BCF or ECF designation applies to class, NOT individual drug • BCF / ECF agents selected from UF agents after UF review

  11. How are Drug Classes Scheduled for UF Review? • Economic impact ($$$) • Existing contracts • Competitive nature of class • Significant clinical developments • New drugs • New clinical evidence • 80 / 20 rule • When to re-review?

  12. UF Decisions, Feb & May 05

  13. UF Decisions, Aug 05

  14. UF Recommendations, Nov 05

  15. Implementation Or, the devil is in the details…

  16. 3rd Tier PrescriptionsAll DoD =MTF + Mail Order + Retail

  17. 3rd Tier PrescriptionsMTF Only

  18. 60,000 NEXIUM - AstraZeneca 50,000 40,000 PREVACID - TAP 30,000 Retail Prescriptions PROTONIX - Wyeth OMEPRAZOLE - Generic 20,000 ACIPHEX – Eisai / J&J 10,000 0 Jul-05 Oct-05 Apr-05 Jan-05 Sep-05 Feb-05 Mar-05 Jun-05 Aug-05 Nov-04 Dec-04 May-05 Decision Date: 18 April 05 Full Implementation Date: 17 July 05 PPIsRetail Prescriptions Implementation Period Decision Date Full Implementation Date

  19. 80,000 70,000 60,000 RABEPRAZOLE 50,000 40,000 LANSOPRAZOLE 30,000 OMEPRAZOLE 20,000 10,000 ESOMEPRAZOLE PANTOPRAZOLE 0 Jul-05 Apr-05 Oct-05 Nov-05 Dec-05 Jun-05 Aug-05 May-05 Sep-05 Decision Date: 18 April 05 Full Implementation Date: 17 July 05 PPIsMTF Rxs

  20. 18,000 IRBESARTAN 16,000 VALSARTAN 14,000 12,000 LOSARTAN 10,000 8,000 6,000 TELMISARTAN CANDESARTAN 4,000 2,000 EPROSARTAN OLMESARTAN 0 Jul-05 Apr-05 Oct-05 Dec-05 Jun-05 Nov-05 Sep-05 Aug-05 May-05 Decision Date: 18 April 05 Full Implementation Date: 17 July 05 ARBsMTF Prescriptions

  21. $2.00 $1.75 Retail $1.50 Overall $1.25 $1.00 Avg Cost Per Day MTF Mail Order $0.75 $0.50 $0.25 Jul-05 Oct-05 Jan-05 Nov-04 Dec-04 Feb-05 Jun-05 Apr-05 Sep-05 Mar-05 May-05 Aug-05 Decision Date: 18 April 05 Full Implementation Date: 17 July 05 ARBsCost Per Day of Therapy – All DoD

  22. 40,000 35,000 30,000 SILDENAFIL 25,000 20,000 15,000 VARDENAFIL TADALAFIL 10,000 5,000 0 Jul-05 Apr-05 Oct-05 Jun-05 Nov-05 Dec-05 Sep-05 Aug-05 May-05 Decision Date: 14 Jul 05 Full Implementation Date: 12 Oct 05 PDE-5sAll DoD Prescriptions

  23. 18,000 16,000 14,000 SILDENAFIL 12,000 VARDENAFIL 10,000 8,000 6,000 4,000 2,000 TADALAFIL 0 Jul-05 Apr-05 Oct-05 Jun-05 Nov-05 Dec-05 Sep-05 Aug-05 May-05 Decision Date: 14 Jul 05 Full Implementation Date: 12 Oct 05 PDE-5sMTF Prescriptions

  24. Decision Date: 14 July 05 Full Implementation Date: 12 October 05 PDE-5sCost Per Tablet – All Points of Service $9.00 $8.00 Retail Overall $7.00 $6.00 Mail Order MTF $5.00 $4.00 $3.00 Jul-05 Oct-05 Nov-05 Jan-05 Jun-05 Nov-04 Feb-05 Apr-05 Dec-04 Mar-05 May-05 Sep-05 Aug-05

  25. PACER • Pharmacy Administration Cost Evaluation Reports • Reports drug use and costs • Compared to other MTFs • Pilot project • 27 selected MTFs • 5 drug classes • PPIs, ARBs, PDE-5s, CCBs, ACEs

  26. MTF Resources For UF Implementation - People • Chain of Command • MTF Commanders • Service consultants • DSCP • Local pricing or prime vendor issues • TMA Pharmacy Program Office • Policy, TRICARE contract issues • PEC • Clinical • MTF support documents • Direct dialog (phone / email) • POC • How do I know if MN or PA or QL exception already approved?

  27. MTF Resources For UF Implementation - Websites • TRICARE Pharmacy website - www.tricare.osd.mil/pharmacy • PA and MN criteria and forms • QLs • DoD P&T Committee minutes • BAP • Formulary Search Tool • PEC website – www.pec.ha.osd.mil • DoD P&T Committee review schedule • PACER reports • RxNet – www.dodrxnet.org • Documents for MTF use - class reviews, monographs, MN forms prior to effective date (Word format) • MTF Info page – summary – www.pec.ha.osd/mil/MTF/UF_Info.htm

  28. MTF Resources For UF Implementation - Websites • TRICARE Pharmacy website - www.tricare.osd.mil/pharmacy • PA and MN criteria and forms • QLs • DoD P&T Committee minutes • BAP • Formulary Search Tool • PEC website – www.pec.ha.osd.mil • DoD P&T Committee review schedule • PACER reports • RxNet – www.dodrxnet.org • Documents for MTF use - class reviews, monographs, MN forms prior to effective date (Word format) • MTF Info page – summary – www.pec.ha.osd/mil/MTF/UF_Info.htm

  29. Summary • Uniform Formulary is here • Changes are coming quickly • MTF support of UF decisions is the law, but is also vital to success • PEC is committed to provide MTF implementation support through multiple venues – but we can’t do it alone.

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