Date post: | 26-Dec-2015 |
Category: |
Documents |
Upload: | chrystal-spencer |
View: | 217 times |
Download: | 0 times |
As of 04/19/23 11
DoD Pharmacoeconomics &
Pharmacy Benefit Conference
January 9th, 2006
Major Travis Watson, MS, USA
Deputy Director, DoD Pharmacy Programs
V5
As of 04/19/23 22
Overview
• DoD Pharmacy Benefit– Demographics
– Utilization
– Structure
• DoD Pharmacy Costs
• Pricing Differences
• Optimized Distribution Model
• Uniform Formulary: Points and Process
As of 04/19/23 33
DoD Pharmacy Program Objectives
• Uniformly, consistently, and equitably provide appropriate drug therapy to meet patients’ clinical needs in an effective, efficient, and fiscally responsible manner
• Provide a World-Class Pharmacy Benefit with a seamless interface between all three points of service
As of 04/19/23 44
TRICARE Eligible BeneficiariesMonthly Average, FY05
Retirees & Family Members < 65
Retirees & Family Members ≥ 65
Active Duty Family Members
Active Duty
1.8M 1.8M
2.3M3.3M 25%36%
19% 19%
Other >1%
FY02 8.6 Million
FY03 8.9 Million
FY04 9.1 Million
FY05 9.2 Million
Source: M2
As of 04/19/23 55
Unique Users by Point of ServiceAll Ages, FY05
MTF
Retail
46% 19% 28%
Mail Order4%
1%
1%1%
Unique Users = 6.6M
Source: PDTS
As of 04/19/23 66
Unique Users - Point of ServiceBy Age, FY04
Retail
MTF
Mail Order
33%19% 25%
3%
14%5%
1%
Unique Users ≥ 65 = 1.3M
Retail
Mail OrderMTF
61%
21%
1%
<1% 1%
1%
15%
Unique Users < 65 = 5.0M
Source: PDTS
As of 04/19/23 77
DoD Pharmacy WorkloadRaw Number of Rx’s Filled
0
10000000
20000000
30000000
40000000
50000000
60000000
MTF Retail Mail
FY04
FY05
As of 04/19/23 88
DoD Pharmacy WorkloadNumber of Rx’s Filled – 30 day Equivalents
0
10000000
20000000
30000000
40000000
50000000
60000000
70000000
80000000
90000000
MTF Retail Mail
FY04
FY05
As of 04/19/23 99
TRICARE Pharmacy Benefit DesignPoint of Service Comparison
MTF(587 Pharmacies)
TMOP(Express – Scripts)
Retail network
(Express – Scripts> 53 K Pharmacies)
Non-network
FormularyMTF-specific(must include Basic
Core Formulary drugs)
TMOP formulary
None(Open)
None(Open)
Co-pay None$3 generic$9 brand (< 90 day supply)
$3 generic$9 brand(< 30-day supply)
Greater of $9 or 20%*(< 30 day supply)
Drug price Federal FederalTransition to
Federal?AWP less?
*Deductibles & point of service penalties also apply
As of 04/19/23 1010
Military Treatment Facility Pharmacy
• 536 DoD Dispensing Pharmacies in 121 MTFs• Beneficiaries have access to prescriptions without co-
pay• Formulary composed of Basic Core Formulary plus
MTF specific additions• Least costly option to patient • Least costly point of service for DoD• 47% Rx workload performed at MTF• 30% of dollars spent*
*Does not include inpatient costs
As of 04/19/23 1111
TRICARE Mail Order Pharmacy
• TMOP Contract awarded to Express Scripts, Inc. 11 Sep 02• Services began 1 Mar 03• Services via state-of-the-art facility in Tempe, AZ dedicated
to DoD workload• Product replenishment through Prime Vendor (McKesson)
at Federal Pricing • DoD Pharmacist as Contracting Officer Representative• Largest commercial mail order account transfer within
industry• 6% of Rx workload performed at TMOP• 12% of dollars spent
As of 04/19/23 1212
TRICARE Retail Pharmacy
• DoD Pharmacist as Contracting Officer Representative• Consolidated retail pharmacy services under a single
contract to optimize benefit management• Consistent benefit across all regions• Portability in 50 states, Guam, Puerto Rico, USVI• Pharmacy Help Desk Services 24 x 7 x 365• TRRx Dedicated Staff• Over 54,000 Retail Pharmacies Now Participate• 47% Rx workload performed at TRRx• 58% of total dollars spent
As of 04/19/23 1313
MHS Pharmacy Benefit UsersBy POS, Jul 01 – Sep 05
Source: PDTS
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Ju
l-01
Sep
-01
No
v-0
1
Ja
n-0
2
Ma
r-02
Ma
y-0
2
Ju
l-02
Sep
-02
No
v-0
2
Ja
n-0
3
Ma
r-03
Ma
y-0
3
Ju
l-03
Sep
-03
No
v-0
3
Ja
n-0
4
Ma
r-04
Ma
y-0
4
Ju
l-04
Sep
-04
No
v-0
4
Ja
n-0
5
Ma
r-05
Ma
y-0
5
Ju
l-05
Sep
-05
Mil
lio
ns
of
Us
ers
MTF
Retail
Mail Order
FY01 FY02 FY03 FY04 FY05
As of 04/19/23 1414
DoD Drug Expenditures thru FY 2005
$617 $662 $741 $797 $878 $1,034 $1,170 $1,388 $1,566 $1,703 $1,615$181 $193 $245 $283 $342$455
$681
$1,279
$1,848$2,430
$3,161$347
$429
$546
$629
$35$83
$106
$191
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Retail
MTFTRICARE Sr. Rx Implementation 1 Apr 2001
Overall 7% 15% 13% 17% 22% 28% 48% 28% 22% 15%
Mail 137% 27% 81% 82% 24% 27% 15%
Retail 7% 27% 16% 21% 33% 50% 88% 45% 32% 30%
MTF 7% 12% 8% 10% 18% 13% 19% 13% 9% -5%
Percent increase over prior year
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
* MTF costs do not Include dispensing costs
* TRRx and TMOP arenet cost to government
Source: PDTS
Millions
As of 04/19/23 1616
Brand Name Drug Acquisition Cost (Indexed to AWP)
AWP
TRRx
TRRx (w/refund)
TMOP
MTFs
$ 100.00
$ 61.00
$ 33.40
$ 40.60
Price Drug Cost
Source: PDTS, 1 Oct 04 – 30 Jun 05, Top 50 TRRx NDCs
FCP $ 50.50
As of 04/19/23 1717
DoD Pharmacy 2006 Program Objectives
• Focus on preserving the benefit• TMOP is the preferred point of service• Co-pays are structured to encourage patients
to make the most efficient choice (TMOP and MTF points of service)
• Expand Utilization Management efforts and data mining
• Ensure the Tpharm contract includes the tools needed to assist DoD to reduce the increase in pharmaceutical costs
As of 04/19/23 1818
Optimized Distribution Model
Mail Order
Preferred Point of Service
-Maintenance meds
- MTF refills
MTF’s
-First fills at MTF*
Retail Network
-Acute medications
*Active duty and their dependents may use MTF for both new and refills if they so choose
As of 04/19/23 1919
Uniform Formulary Is a Critical Management Tool
• Formulary management and tiered co-pays are industry standards and best commercial business practices used to manage a pharmacy benefit
• Historically, formulary management was not uniform across the Military Health System– TMOP: Had been determined by DoD Pharmacy
and Therapeutics Committee (P&T)– Direct Care: Had been Basic Core Formulary via
DoD P&T plus local Facility P&T decisions– TRRx: Had been an open formulary, except for
those excluded by law
As of 04/19/23 2222
Key Points Uniform Formulary
• Encourages use of more cost-effective POS• Influences beneficiary and provider choice• Permits tiered co-pays: Generic, Formulary, NF• Allows beneficiaries to obtain NF drugs that are
“clinically necessary” at the 2nd Tier co-pay• Permits Prior Authorization • Requires Non-formulary drug availability• New DoD P&T and UF Beneficiary Advisory Panel
As of 04/19/23 2323
Department of Defense Pharmacy & Therapeutics Committee
DoD P&TMakes
Recommendations
PECCollectsAnalyzesPresents
Minutes posted
BAPComments
TMA DirectorMakes Decisions
DoD P&TMakes Decisions
PECCollectsAnalyzesPresents
Minutes posted
Old
New
As of 04/19/23 2424
Committee Responsibilities
• Evaluate clinical effectiveness and cost effectiveness of pharmaceutical agents
• Recommend pharmaceutical agents for:– Uniform Formulary– Basic Core Formulary– Extended Core Formulary
• Medical necessity criteria for drugs classified as non-formulary (3rd tier)
• Restrictions / limitations– Prior authorization– Quantity limits– TRRx and TMOP
As of 04/19/23 2525
DoD P&T Committee Voting MembersYour Representatives
• Physician Chairman (HA/TMA)• Director, DoD Pharmacy Programs, TMA• Director, DoD PEC• Internal Medicine providers from each service• Pediatrician from one service (Army)• Family Practice from one service (Navy)• OB/Gyn from one service (AF)• One provider at large from each service• One pharmacist from each service• Coast Guard: one physician or pharmacist• Department of VA : one physician or pharmacist• TRRx COR• TMOP COR
As of 04/19/23 2626
DoD P&T Committee Non-Voting Members
• JRCAB (readiness folks)
• TMA General Counsel
• TMA Resource Management Directorate
• Defense Supply Center Philadelphia
As of 04/19/23 2727
Beneficiary Advisory Panel (BAP)
• Operates under Federal Advisory Committee Act (FACA) and provides new level of accountability and oversight for the UF process
• Purpose is to provide beneficiaries a voice and representation in the UF process
• Members consist of nominees from major beneficiary representative organizations such as MOAA, contractors, professionals
As of 04/19/23 2828
DoD Core Formularies(Ref: HA 04-032)
• All drug classes will fall under either– Basic Core Formulary (generally primary care)– Extended Core Formulary (all other classes,
generally specialized care)• Drugs are selected for the BCF or ECF because they
provide greater value than other drugs on the Uniform Formulary
• Where clinically appropriate, MTFs should maximize the use of BCF and ECF drugs over other UF drugs
As of 04/19/23 2929
MTF Formulary Management(Ref: HA 04-032)
• MTF Formularies must contain:– BCF drugs– ECF drugs in each ECF drug class that is included on the
MTF formulary• MTF Formularies may also contain:
– Other UF drugs: generic (1st tier) or formulary (2nd tier)– Drug used solely for inpatient services– Medications not covered by TRICARE pharmacy benefit that
are allowed to be covered by MTFs• OTCs, weight loss meds, smoking cessation, etc.
• MTF Formularies cannot contain:– Drugs classified as non-formulary on UF (3rd tier)
As of 04/19/23 3434
Non-formulary Agents(Ref: HA 04-032)
• $22 cost share per prescription at Mail Order and Retail - no questions asked
• $9 cost share if medical necessity is validated• Excluded from all MTF formularies
– Available only upon approval from non-formulary special order process that validates Medical Necessity criteria established by the DoD P&T Committee
• MTF non-formulary special order process can only be used by:– MTF providers – Prescriptions written by a civilian provider to whom the
patient was referred by the MTF
As of 04/19/23 3535
Chief of Pharmaceutical Operations
Chief of PharmaceuticalOperations
DirectorDoD Pharmacy
Programs and Operations(CDR Blanche)
HomelandSecurity
Immunizations/Vaccines
External Communications
Secretary1 Additional Billet