Formulary

Clinical depression is a major problem in the United States, affecting an estimated 5% to 10% of all adults. Costs for medical care and lost productivity related to depression are estimated at more than $40 billion per year.

PPOS are seeing a continued resurgence in some areas, and in others, are not able to compete effectively with HMOs, industry experts say.

A value-based formulary takes into account individual illnesses and varies financial incentives determined by how important a medication is to a patient.

A value-based formulary takes into account individual illnesses and varies financial incentives determined by how important a medication is to a patient.

As payers have been increasingly impacted by rising drug costs, they have become more creative in plan design by introducing different copay tiers and member incentives to change drug purchasing behavior, say industry watchers.

Payers and employers can pay up to $350,000 per patient for just one year of treatment for high-cost conditions such as rheumatoid arthritis. Patients, too, share the burden, in some cases shouldering 50% of the bill in deductibles and co-pays.

Antipsychotics are the fourth largest group of medications prescribed in the United States today, with a collective cost of approximately $10 billion. Newer, second-generation medications represent 90% of the current market, and they cost considerably more than older antipsychotics.

THE BEST STEP therapy programs first consider medical evidence regarding patient outcomes when identifying drug classes for inclusion, according to industry experts.

What makes the high cost of a drug worth it? Does the intervention have to save a life? Or prevent the onset of a more expensive condition? Or add six months to patient survival? It's all in the eye of the beholder-whether you are a payer, patient or provider.

Over the next few years, more health plans and employers will investigate covering the physician-administered injectable drugs under the pharmacy benefit as a way to control the costs and manage appropriate utilization, says Kathryn Lindhorst Canaday, PharmD, director of pharmacy analysis, Pharmaceutical Strategies Group (PSG), based in Dallas.

Although as many as 48% of seniors were subject to some type of drug-coverage deficiency in 2006, only an estimated 4 million of the 22.5 million enrolled in Medicare drug plans were actually expected to hit the infamous donut hole. There could still be financial woes, however, for the 10.8 million Medicare beneficiaries who at least have the potential for out-of-pocket costs in the donut hole gap because they do not qualify for a subsidy, are not covered outside Part D, or did not pay for enhanced gap coverage.