impact of the pharmacy closed formulary · 2020. 7. 15. · february 2015 3 . summary of key...
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Impact of the Texas Pharmacy Closed Formulary
A Preliminary Report Based on 12-month Injuries with 24-month Services
and Legacy Status
Texas Department of Insurance Workers’ Compensation Research and Evaluation Group
February 2015
February 2015 2
Data and methods
• Injury months: 12 months (September–August) • Injury years: 2009–2011 • Prescription months: 24 months maturity per claim • Injuries in 2011 are new injuries that occurred after the
implementation of the pharmacy closed formulary – Injury year from September 2011 to August 2012 – Services covering from September 2011 to August 2013
• Not Recommended drugs (N-drugs) list: approximately 150 drugs that require carrier preauthorization
• Key measures: Claim counts Prescription costs Prescription utilization patterns
Generic substitution rates Cost and utilization by drug group Most prescribed drugs
February 2015 3
Summary of key findings: New claims
New claims with injuries that occurred on or after September 1, 2011 are subject to the implementation of the Pharmacy Closed Formulary.
• The number of injured employees receiving N-drugs fell by 65 percent.
• N-drug costs fell by 83 percent, and N-drug costs as a percentage of all drug costs decreased by 79 percent (from 17 percent of total to 3 percent of total).
• The number of injured employees receiving other drugs fell by 1 percent.
• The share of N-drug claims among all claims fell from 18 percent to 7 percent.
• The total number of prescriptions for N-drugs fell by 76 percent while it fell by 4 percent for other drugs.
• The average number of N-drug prescriptions per claim fell by 31 percent.
• The generic substitution rate for N-drugs increased from 61 percent in 2010 to 74 percent in 2011.
• The number of N-drug prescriptions fell by 65+ percent across all drug groups.
• The number of prescriptions for the ten most-prescribed N-drugs decreased by 82 percent.
February 2015 4
Summary of key findings: Legacy claims
Legacy claims with injuries prior to September 1, 2011 are subject to the Pharmacy Closed Formulary beginning on September 1, 2013.
• Legacy claims accounted for 38 percent of the claims and 57 percent of the total pharmacy cost in September 2014.
• Legacy claims serviced in a month decreased from 35,604 in September 2011 to 12,215 in September 2014 (66 percent decrease), mainly because there are no new claims added.
• The average pharmacy cost per legacy claim dropped by 18 percent in the first month they became subject to the pharmacy closed formulary (September 2013).
• Total cost of N-drugs decreased from $1.42 million in August 2013 to $607,000 in September 2013 (57 percent decrease), and decreased to $290,000 in September 2014.
• For legacy claims, the share of N-drug cost in the total cost dropped from 18.5 percent in August 2013 to 10.4 percent in September 2013 (44 percent decrease). N-drugs accounted for 6 percent of the total cost in September 2014.
February 2015 5
New Claims
with Injury Dates on or after September 1, 2011
(Subject to the Pharmacy Closed Formulary Beginning on September 1, 2011)
February 2015 6
New Claims: Number of Claims
February 2015 7
Number of claims receiving pharmaceuticals, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
Injury year 2010-2011
percentage change 2009 2010 2011
All claims 106,113 108,642 105,847 -3%
N-drugs
Number of claims 20,966 20,013 6,954 -65%
Percent of all claims 20% 18% 7% -64%
Other drugs
Number of claims with at least one Other drug 103,671 106,313 105,312 -1%
Number of claims with Other drugs only (no N-drugs) 85,147 88,629 98,893 12%
Percent of all claims 80% 82% 93% 15%
February 2015 8
Number of claims, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
106,113 108,642 105,847
85,147 88,629
98,893
20,966 20,013
6,954
0
20,000
40,000
60,000
80,000
100,000
120,000
2009 2010 2011
All claims
Without N-drugs
With N-drugs
February 2015 9
New Claims: Prescription Costs
February 2015 10
Cost of N-drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
Injury year 2010-2011 percentage
change 2009 2010 2011
Total cost $46,234,636 $44,504,995 $37,759,827 -15%
Total cost of N-drug prescriptions $9,609,117 $7,345,534 $1,283,864 -83%
N-drug cost as a percentage of total drug costs 21% 17% 3% -79%
Total number of N-drug prescriptions 76,147 63,343 15,284 -76%
Average cost per N-drug prescription $126 $116 $84 -28%
Total number of N-drug claims 20,966 20,013 6,954 -65%
Average N-drug cost per claim $458 $367 $185 -50%
February 2015 11
Total and average costs: N-drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$401
$328
$168
$124 $113 $81
$9,609,117
$7,345,534
$1,283,864
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
$0
$100
$200
$300
$400
$500
2009 2010 2011
Cost per claim Cost per prescription Total N-drug cost
February 2015 12
Cost of Other drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
Injury year 2010-2011 percentage
change 2009 2010 2011
Total cost $46,234,636 $44,504,995 $37,759,827 -15%
Total cost of Other drug prescriptions $36,625,519 $37,159,460 $36,475,964 -2%
Other drug cost as a percentage of total drug costs 79% 83% 97% 16%
Total number of Other drug prescriptions 632,739 648,672 624,676 -4%
Average cost per Other drug prescription $58 $57 $58 2%
Total number of Other drug claims 103,671 106,313 105,312 -1%
Average Other drug cost per claim $353 $350 $346 -1%
February 2015 13
Total and average costs: Other drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$353 $350 $346
$58 $57 $58
$36,625,519 $37,159,460 $36,475,964
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
$30,000,000
$35,000,000
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500
2009 2010 2011
Cost per claim Cost per prescription Total Other drug cost
February 2015 14
New Claims: Prescription Patterns
February 2015 15
Share of prescriptions by drug type, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
Injury year 2010-2011
percentage change 2009 2010 2011
Total number of all prescriptions 708,886 712,015 639,960 -10%
N-drugs
Number of prescriptions 76,147 63,343 15,284 -76%
N-drug prescriptions as a percent of all prescriptions 11% 9% 2% -73%
Other drugs
Number of prescriptions 632,739 648,672 624,676 -4%
Other drug prescriptions as a percent of all prescriptions 89% 91% 98% 7%
February 2015 16
Number of prescriptions per claim, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
Injury year 2010-2011 percentage
change 2009 2010 2011
N-drugs
Number of prescriptions 76,147 63,343 15,284 -76%
Total N-drug claims 20,966 20,013 6,954 -65%
Number of prescriptions per claim 3.63 3.17 2.20 -31%
Other drugs
Number of prescriptions 632,739 648,672 624,676 -4%
Total Other drug claims 103,671 106,313 105,312 -1%
Number of prescriptions per claim 6.10 6.10 5.93 -3%
February 2015 17
New Claims: Generic Substitution Rates
February 2015 18
Generic substitution: prescriptions of N-drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
24,482
3,983
38,861
11,301
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
2010 2011
Brand Generic
(39%)
(61%)
(26%)
(74%)
February 2015 19
Generic substitution: prescriptions of Other drugs, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
62,707 49,217
572,270 559,035
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
2010 2011
Brand Generic
(90%)
(10%) (8%)
(92%)
February 2015 20
Average number of N-drug prescription days by generic status, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
22.8 20.4 20.5 19.9
0.0
5.0
10.0
15.0
20.0
25.0
2010 2011
Brand Generic
February 2015 21
New Claims: Cost and Utilization by Drug Group
February 2015 22
Number of prescriptions by drug group, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
N-drug Status Drug group
Number of prescriptions
2010
Number of prescriptions
2011
2010 - 2011 percentage
change
N-drugs
Analgesics - Anti-Inflammatory 15,138 3,455 -77%
Analgesics - Opioid 8,188 2,875 -65%
Central Nervous System Drugs 15,728 4,442 -72%
Musculoskeletal Therapy Agents 13,300 1,703 -87%
Others 10,989 2,809 -74%
Total 63,343 15,284 -76%
Other drugs
Analgesics - Anti-Inflammatory 154,030 153,521 0%
Analgesics - Opioid 231,971 209,989 -9%
Central Nervous System Drugs 45,549 43,583 -4%
Musculoskeletal Therapy Agents 90,891 90,787 0%
Others 126,231 126,796 0%
Total 648,672 624,676 -4%
February 2015 23
Total cost by drug group, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
N-drug Status Drug group Total cost
2010 Total cost
2011
2010 - 2011 percentage
change
N-drugs
Analgesics - Anti-Inflammatory $1,723,884 $204,116 -88%
Analgesics - Opioid $1,264,710 $346,970 -73%
Central Nervous System Drugs $1,025,308 $285,451 -72%
Musculoskeletal Therapy Agents $1,064,535 $67,239 -94%
Others $2,267,097 $380,087 -83%
Total $7,345,534 $1,283,864 -83%
Other drugs
Analgesics - Anti-Inflammatory $9,755,521 $9,535,053 -2%
Analgesics - Opioid $7,651,679 $6,489,643 -15%
Central Nervous System Drugs $5,798,464 $5,697,524 -2%
Musculoskeletal Therapy Agents $5,539,819 $5,032,235 -9%
Others $8,413,977 $9,721,508 16%
Total $37,159,460 $36,475,964 -2%
February 2015 24
Average cost per claim by drug group, by injury year (Sept.–Aug.)
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
N-drug Status Drug group
Number of claims Cost per claims
2010 2011 2010 2011 2010 - 2011 percentage
change
N-drugs
Analgesics - Anti-Inflammatory 8,444 2,328 $204 $88 -57%
Analgesics - Opioid 2,978 1,267 $425 $274 -36%
Central Nervous System Drugs 3,863 1,441 $265 $198 -25%
Musculoskeletal Therapy Agents 4,816 969 $221 $69 -69%
Others 4,538 1,737 $500 $219 -56%
Other drugs
Analgesics - Anti-Inflammatory 62,672 64,042 $156 $149 -4%
Analgesics - Opioid 59,897 59,012 $128 $110 -14%
Central Nervous System Drugs 8,109 7,922 $715 $719 1%
Musculoskeletal Therapy Agents 34,763 35,761 $159 $141 -12%
Others 46,642 47,271 $180 $206 14%
February 2015 25
New Claims: Most Prescribed Drugs
February 2015 26
Ten most frequently prescribed drugs, by injury year (Sept.–Aug.)
Note: No N-drug was in the top ten most frequently prescribed drugs in 2010 and 2011. These ten drugs accounted for 60 percent of total prescriptions in 2010, and 65 percent in 2011. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
2010 rank by number of
prescription Drug name Drug group
Number of prescriptions
2010
Number of prescriptions
2011
1 Hydrocodone/APAP Analgesics - Opioid 158,576 138,468
2 Cyclobenzaprine Musculoskeletal Therapy Agents 56,090 56,917
3 Naproxen Analgesics - Anti-Inflammatory 49,775 50,186
4 Tramadol Analgesics - Opioid 47,521 49,238
5 Ibuprofen Analgesics - Anti-Inflammatory 47,167 49,846
6 Meloxicam Analgesics - Anti-Inflammatory 20,493 21,913
7 Celebrex Analgesics - Anti-Inflammatory 14,308 12,083
8 Gabapentin Central Nervous System Drugs 12,774 13,861
9 Tramadol/APAP Analgesics - Opioid 12,292 12,909
10 Methylpred Others 10,606 11,425
Subtotal 429,602 416,846
February 2015 27
Ten most frequently prescribed N-drugs, by injury year (Sept.–Aug.)
Note: These ten drugs accounted for 59 percent of total N-drug prescriptions in 2010, and 44 percent in 2011. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
2010 rank by number
of Rx Drug name Drug group Number of
Rx in 2010 Number of Rx in 2011
2010-2011 percentage
change
1 Carisoprodol Musculoskeletal Therapy Agents 8,514 1,086 -87%
2 Diclofenac Analgesics - Anti-Inflammatory 4,874 1,944 -60%
3 Zipsor Analgesics - Anti-Inflammatory 3,867 465 -88%
4 Lidoderm Others 3,829 744 -81%
5 Diazepam Central Nervous System Drugs 3,314 771 -77%
6 Naprelan Analgesics - Anti-Inflammatory 2,952 218 -93%
7 Hydrocodone/IBU Analgesics - Opioid 2,541 660 -74%
8 Alprazolam Central Nervous System Drugs 2,503 399 -84%
9 Flector Others 2,454 338 -86%
10 Amrix Musculoskeletal Therapy Agents 2,236 34 -98%
Subtotal 37,084 6,659 -82%
February 2015 28
Legacy Claims
with Injury Dates Prior to September 2011
(Subject to the Pharmacy Closed Formulary Beginning on September 1, 2013)
February 2015 29
All claims: Number of claims and total cost by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$0
$2
$4
$6
$8
$10
$12
$14
$16
20,000
25,000
30,000
35,000
40,000
45,000
50,000
55,000
60,000 20
05/0
1 20
05/0
4 20
05/0
7 20
05/1
0 20
06/0
1 20
06/0
4 20
06/0
7 20
06/1
0 20
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1 20
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4 20
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7 20
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0 20
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1 20
08/0
4 20
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7 20
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0 20
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1 20
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4 20
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7 20
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0 20
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1 20
10/0
4 20
10/0
7 20
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0 20
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1 20
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4 20
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7 20
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0 20
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1 20
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4 20
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7 20
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0 20
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1 20
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4 20
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7 20
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0 20
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1 20
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4 20
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7
Mill
ions
Number of Claims Served per Month Total Cost per Month
New claims subject to Formulary
Legacy claims subject to Formulary
February 2015 30
Number of claims by claim type by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000 20
11/0
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0 20
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1 20
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2 20
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1 20
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3 20
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6 20
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7 20
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8 20
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9 20
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0 20
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1 20
13/1
2 20
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1 20
14/0
2 20
14/0
3 20
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4 20
14/0
5 20
14/0
6 20
14/0
7 20
14/0
8 20
14/0
9
Legacy claims
New claims
Total claims
February 2015 31
Total pharmacy costs by claim type by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$0
$2
$4
$6
$8
$10
$12
$14 20
11/0
1 20
11/0
2 20
11/0
3 20
11/0
4 20
11/0
5 20
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6 20
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7 20
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9 20
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0 20
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1 20
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2 20
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1 20
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3 20
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5 20
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6 20
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7 20
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8 20
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9 20
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0 20
12/1
1 20
12/1
2 20
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1 20
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2 20
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3 20
13/0
4 20
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5 20
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6 20
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7 20
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8 20
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9 20
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0 20
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1 20
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2 20
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1 20
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2 20
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3 20
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4 20
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5 20
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6 20
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7 20
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8 20
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9
Mill
ions
Legacy claims
New claims
February 2015 32
Average pharmacy cost per claim by claim type by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500 20
11/0
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2 20
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1 20
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3 20
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4 20
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5 20
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6 20
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7 20
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8 20
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9 20
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0 20
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1 20
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2 20
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1 20
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2 20
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3 20
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4 20
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6 20
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7 20
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8 20
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0 20
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1 20
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2 20
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1 20
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2 20
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3 20
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4 20
14/0
5 20
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6 20
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7 20
14/0
8 20
14/0
9
Legacy claims
New claims
February 2015 33
Legacy claims: Costs of N-drugs and other drugs by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
$0
$2
$4
$6
$8
$10
$12
$14
$16 20
11/0
1 20
11/0
2 20
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3 20
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4 20
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5 20
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6 20
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8 20
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0 20
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1 20
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2 20
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1 20
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2 20
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3 20
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4 20
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5 20
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6 20
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7 20
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8 20
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9 20
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0 20
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1 20
12/1
2 20
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1 20
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2 20
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3 20
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4 20
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5 20
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6 20
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7 20
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8 20
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0 20
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1 20
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2 20
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1 20
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2 20
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3 20
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4 20
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6 20
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7 20
14/0
8 20
14/0
9
Mill
ions
Other drugs
N-drugs
February 2015 34
Share of N-drug cost in the total cost by claim type by service month
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2015.
0%
5%
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4 20
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5 20
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6 20
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7 20
14/0
8 20
14/0
9
Legacy claims
New claims
REG’s main Web page at the Texas Department of Insurance: www.tdi.texas.gov/wc/regulation/roc
For more information, contact us at [email protected].
Per Chapter 405 of the Texas Labor Code, the Workers' Compensation Research and Evaluation Group at the Texas Department of Insurance is responsible for conducting professional studies and research on various system issues, including:
• the delivery of benefits; • litigation and controversy related to workers' compensation; • insurance rates and rate-making procedures; • rehabilitation and reemployment of injured employees; • the quality and cost of medical benefits; • employer participation in the workers' compensation system; • employment health and safety issues; and • other matters relevant to the cost, quality, and operational effectiveness of the workers' compensation system.