Towards

1
Towards Values-Based formularies Generic
uptake, sustainability and safety.

• Value of Generics Conference
• Montreal, P.Q.
• October 26, 2011.  

Alan Cassels, University of Victoria.
cassels_at_uvic.ca
2
I am
Supported by research grants, contracts related
to health reporting and a UVIC research salary
3
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.

4
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 dont cost me anything, theyre free.

5
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.

6
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
7
What are we actually covering?Top Therapeutic
Classifications 2009
Avg Cost Paid by Disease
colour 1) Cholesterol disorders 72.60 9.8
GREEN 2) Blood pressure 31.66 7.9
PINK 3) Diabetes 51.67 6.8 4)
Depression 45.69 6.7 5) Ulcers 52.98 6.
4 YELLOW 6) 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
8
Top 25
RANK NAME SCRIPTS DIN COST PAID COST PER SCRIPT
1 REMICADE INJECTION 12,625 54,759,926 4,337.42
2 NEXIUM 40MG TABLET 355,983 34,766,372 97.66
3 CRESTOR 10MG TABLET 399,830 34,495,778 86.28
4 HUMIRA 40MG/0.8ML PFS INJ 13,533 28,728,311 2,122.83
5 ENBREL 50MG INJECTION 12,145 25,471,235 2,097.26
6 PLAVIX 75MG TABLET 145,387 18,907,467 130.05
7 CRESTOR 20MG TABLET 168,238 18,023,262 107.13
8 EZETROL 10MG TABLET 142,409 15,443,547 108.45
9 SYMBICORT 200 TURBUHALER 143,506 15,412,380 107.40
10 CELEBREX 200MG CAPSULE 191,909 12,652,487 65.93
11 CIPRALEX 10MG TABLET 139,645 12,356,598 88.49
12 COPAXONE 20MG/ML PFS 7,655 12,255,407 1,600.97
13 CYMBALTA 60MG DR CAPSULE 66,659 11,631,880 174.50
14 ADVAIR 250UG INHALATION DISKUS 82,897 11,213,330 135.27
15 SINGULAIR 10MG TABLET 80,372 10,332,257 128.56
16 NEULASTA 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 36.87
18 CRESTOR 5MG TABLET 110,289 9,136,643 82.84
19 ONE TOUCH ULTRA BLUE TEST STRIP (ON) 77,488 8,790,169 113.44
20 LYRICA 75MG CAPSULE 57,003 8,288,399 145.40
21 SPIRIVA 18MCG CAPSULE 72,619 8,167,883 112.48
22 JANUVIA 100MG TABLET 51,548 8,159,687 158.29
23 AVONEX PS 30MCG/0.5ML SYR 4,099 7,506,267 1,831.24
24 CIPRALEX 20MG TABLET 79,711 7,433,866 93.26
25 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.
9
Next top 25
RANK 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 59.08
28 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 6,538,657 196.22
32 LIPITOR 10MG TABLET 79,872 6,524,926 81.69
33 ADVAIR 250MCG MD INHALER 35,429 6,280,752 177.28
34 BOTOX 50U/100U/200U VIAL 8,654 6,215,217 718.19
35 GLEEVEC 400MG TABLET 1,507 6,099,776 4,047.63
36 STELARA 45MG/0.5ML INJECTION 1,141 5,871,635 5,146.04
37 DIOVAN 80MG TABLET 77,154 5,676,420 73.57
38 NOVORAPID 100U/ML INSULIN CARTRIDGE 56,239 5,626,102 100.04
39 MICARDIS 80MG TABLET 76,465 5,549,471 72.58
40 APO-ATORVASTATIN 10MG TABLET 115,972 5,530,186 47.69
41 CONTOUR TEST STRIP (ON) 48,856 5,488,058 112.33
42 LANTUS SOLOSTAR 100U/ML PREFILL PEN 5X3ML 37,986 5,427,347 142.88
43 BIAXIN 500MG XL TABLET 103,797 5,391,436 51.94
44 NEUPOGEN 300MCG/ML VIAL 3,577 5,379,047 1,503.79
45 AVAPRO 150MG TABLET 72,976 5,369,313 73.58
46 CRESTOR 40MG TABLET 45,109 5,251,928 116.43
47 COVERSYL 8MG TABLET 71,780 5,236,177 72.95
48 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
10
Sheilas got heartburn

• Office Administrator. 34 years old
• She has been taking Losec (omeprazole) for years.
  It works great.
• She feels its worth every penny of the 112 per
  month. Her plan is a 20 deductible so her cost
  is 22 per month employer pays 90.
• Whats wrong with this picture?

11
Sheilas 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 doesnt
  her private drug plan follow?

12
Proton Pump Inhibitors
PPIS
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 3,968,654 PANTOPRAZOLE 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
13
Proton Pump Inhibitors
PPIS
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 3,968,654 PANTOPRAZOLE 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
14
PPI Special authority form, BC Pharmacare
15
What is the basis for BC PharmaCares Special
Authority process around PPIs?

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

16
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)its 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
• Whats wrong with this picture?

17
Peters 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
  Pharmacares formulary rules hed need to try an
  ACE-inhibitor first.
• The Municipal Pension plan got rid of its dental
  coverage and may dump its drug coverage. Why?
  Its unsustainable.

18
Top drugs for hypertension
RANK 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
19
Top drugs for hypertension
RANK 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
20
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

21
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.
• Whats wrong with this picture?

22
Marges 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.

23
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
24
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
25
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

26
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)

27
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.

28
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 dont cost anything,
  theyre free!

29
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 dont cost me anything, theyre free.

30
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?

31

• How to contact me
• Alan Cassels
• University of Victoria
• cassels_at_uvic.ca
• 250 361 3120