Table 1
Selected Strategies for Containing Pharmacy Costs |
STRATEGY |
PLAN AND COMMUNITY |
YEAR INTRODUCED |
CHARACTERISTICS |
Benefit Design |
Three-tier copayment benefit |
AvMed, Miami |
2000 |
$10 copayment for generics, $20 preferred brands, $30
for non-preferred drugs |
Three-tier coinsurance benefit |
Regence BlueShield, Seattle |
2000 |
10 percent coinsurance for generics, 30 percent for preferred
brands, 50 percent for non-preferred brands |
Reference pricing |
Blue Cross of Calif., Orange County |
2002 (expected) |
A fixed monthly drug benefit for each therapeutic class;
patients pay costs exceeding cap |
Drug Selection |
Closed formulary |
BC/BS of Mass., Boston |
1999 |
Covers formulary drugs only unless plan grants exception
for medical necessity |
Formulary exclusions |
Arkansas BC/BS, Little Rock |
2000 |
Excludes second-generation drugs that replace older drugs
facing patent expiration |
Utilization
Management |
Physician profiling with prompts |
Tufts Health Plan, Boston |
1998 |
Identifies patients who could be switched to less-expensive
drugs and sends detailers to consult physicians and place prompts in medical
charts |
Prior authorization |
Blue Cross of Calif., Orange County |
2000 |
Requires prior authorization for drugs subject to misuse |
Pharmacy management bonus |
Arkansas BC/BS, Little Rock |
2000-01 (pilot test) |
Provides physicians with a bonus if established drug
utilization targets are met |
Purchasing
Strategies |
Mail order pharmacy option |
CIGNA, Greenville, S.C. |
2000 |
33 percent discount on consumer copayment if drugs are
ordered through mail order option |
Preferred buying |
Blue Cross of Calif., Orange County |
1997 |
Negotiates discounts directly with manufacturers in
exchange for placing drugs on preferred tier |
BC/BS = Blue Cross and Blue
Shield |