Same Tools Used in Members of Congress’ Own Health Plan

(Washington, DC)—A report issued today by the Minority Staff of the House Government Reform Committee confirms that seniors have wide access to the top 100 prescription drugs seniors rely upon, but fails to recognize the value of pharmacy management tools in promoting quality, expanding access, and controlling costs, the Pharmaceutical Care Management Association (PCMA) said today.

PCMA is the national association representing America’s pharmacy benefit managers (PBMs). PBMs administer prescription drug plans for more than 200 million Americans with health coverage provided through small businesses, Fortune 500 employers, health insurers, labor unions, and the Medicare program’s stand-alone prescription drug plans (PDPs) and Medicare Advantage plans.

“This new report from the minority staff of the House Government Reform Committee confirms that Medicare prescription drug plans are relying on these same pharmacy management tools that Members of Congress’ own health plan use to control costs while ensuring broad access to the drugs beneficiaries need,” said PCMA President Mark Merritt.

Mr. Merritt added, “Regrettably, the report ignores the value of pharmacy management tools. Pharmacy management tools have improved the quality of life for millions of Americans through better outcomes; saved billions of dollars for private and public purchasers; and made prescription drugs more affordable for working families.”

Pharmacy management tools such as prior authorization, step therapy, and quantity limits play a critical role in improving quality and constraining costs:

Prior Authorization (PA). When a drug is designated as subject to prior authorization on a plan’s formulary, it means that the plan must communicate with the prescribing physician about the particular patient’s diagnosis and whether there are alternative medications that may be more clinically appropriate. For those on maintenance medications used to treat chronic conditions, this process typically occurs only once and future refills are authorized typically without PA.

Step Therapy (ST). Step therapy is used to ensure that patients are prescribed first-line therapies for certain conditions before they utilize more powerful, more costly, and/or potentially more dangerous drugs. Drugs identified for step therapy require plan pre-approval prior to pharmacy dispensing. This generally involves communicating with the prescribing physician. If the first line therapy does not work, the patient should move to the second-line therapy, and so on. One large national PBM has estimated its clients can save 10 percent or more on overall drug spend when fully utilizing step therapy programs.
[1]

Quantity Limits (QL) . Quantity limits are often applied to certain medications to ensure proper prescription compliance by the patient. Drugs subject to quantity limits are often narcotics (i.e, Oxycontin), other drugs used primarily for sporadic or short-term use (i.e., Ambien) or so-called “lifestyle” drugs, though such limits may also be used more broadly. Overrides of drug quantity limitations do not typically require immediate physician intervention. Instead, patients fill their prescription for the allowable amount and the pharmacy/PBM will make a subsequent request for information from the physician to justify the override.

[1] Express Scripts, “2004 Drug Trend Report,” June 2005

###

The Pharmaceutical Care Management Association (PCMA) is the national trade association representing America’s pharmacy benefit managers (PBMs). PCMA member companies provide pharmaceutical care management services to more than 200 million Americans.

Contact Information:
Phil Blando, 202-207-3614
Charles Coté 202-207-3605