Journal of managed care pharmacy : JMCP
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Comparative Study
Comparison of mail-order with community pharmacy in plan sponsor cost and member cost in two large pharmacy benefit plans.
Pharmacy benefit managers (PBMs) play a major role in administering prescription drug benefit programs for health plans and employers. PBMs have often encouraged the use of self-owned mail-order pharmacy services with the promise to plan sponsors of lower prescription drug costs compared with those of the community pharmacy network. Some plan sponsors have requested a higher degree of disclosure of contract relationships and transparency in pricing. Unfortunately, little research exists based on empirical data to determine the net plan cost and member cost for mail-order drugs, as opposed to having these drugs dispensed by community pharmacies. ⋯ Overall, savings from lower unit pricing through the mail-order channel benefited the member and did not translate into significant cost reductions for the plan sponsor. In both pharmacy benefit plans, the plan sponsor either realized small savings or incurred slightly higher costs when paying for drugs in the top therapeutic categories through the mail-order channel. Some generic drug prices are higher through mail-order pharmacy than through community pharmacy, and 1 of the 2 plans in this study paid higher net costs after member cost share for generic drugs through mail order.
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Total knee replacement (TKR), a last resort for treating knee pain due to osteoarthritis (OA), is not always medically indicated or preferred by many patients. Hylan G-F 20 is a cross-linked hyaluronan derivative approved for the treatment of pain due to OA of the knee after other conservative approaches have failed. ⋯ In patients who are candidates for TKR, the need for TKR can be delayed with hylan G-F 20 when used for the treatment of OA knee pain.
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The Medicare Modernization Act of 2003 requires drug plan sponsors to provide medication therapy management programs (MTMPs) to beneficiaries with (1) drug expenditures above $4,000, (2) multiple comorbidities, and (3) multiple prescription drugs. The Medical Expenditure Panel Survey (MEPS) is a national probability survey conducted annually by the Agency for Healthcare Research and Quality and the National Center for Health Statistics to provide nationally representative estimates of health care use, expenditures, sources of payments, and insurance coverage for the U.S. civilian noninstitutionalized population. MEPS comprises 3 components, including the household component (HC) in which households and individuals within households are sampled. The medical provider component (MPC) supplements the HC by contacting providers (hospitals, outpatient offices, home health agencies, and pharmacies) reported in the HC, and the insurance component collects data on health insurance plans and is separate from the HC. ⋯ MEPS survey respondents aged 65 years or older with drug expenditures exceeding the MTMP threshold of $4,000 per year obtain substantially more drugs and have a higher disease burden than those with lower drug expenditures. Characteristics other than drug use, such as having functional limitations or requiring help with activities of daily living, can be used to identify potential MTMP candidates.