0508DBT200247IDM.lay 11/9/05 12:34 PM Page 334 Issues in Drug Benefit

Evaluating OTC Coverage Options
Irecently had the opportunity to discuss whether plans makes this the only exception to the plans’ exclusion of should cover OTC medications with several of my col- leagues in managed care. Although coverage of OTC In general, I applaud the efforts of pharmacy direc- agents is common in managed Medicaid plans, most com- tors to look for innovative ways of providing effective, mercial plans do not provide such coverage. The new cost-efficient therapy. But if plans are covering one OTC Medicare Part D benefit, which will be implemented in medication, why aren’t they covering others? Could pro- January 2006, also does not cover OTC medications.
viding coverage for just one OTC product or a selected The issue of OTC coverage has recently resurfaced therapeutic category of OTC agents help establish a sys- with the introduction of OTC Claritin and Prilosec OTC.
tem in which enrollees could claim “discrimination” be- In the past, pharmacy directors at MCOs were happy cause their OTC medication is not covered? In addition, when prescription drugs were switched to OTC status it is likely that other agents in the proton pump inhibitor because plans could save money by dropping coverage (PPI) class will become available OTC in the near future.
of OTC medications. Although it could be argued that Will the plans that cover Prilosec OTC also need to covering the OTC version in lieu of the more expensive include the OTC versions of the other PPIs as they are in- prescription drug can be cost-effective, most pharmacy troduced, or will these plans decide to reverse their cov- directors used the “it’s too hard to administer” excuse to erage policy for Prilosec OTC and exclude coverage of all avoid adding OTCs to the pharmacy benefit.
PPIs if the entire class switches to OTC status? If plans do In my conversations with several pharmacy direc- reverse their decision, how do they handle the enrollees tors, I learned that many plans are now covering Prilosec who are currently receiving coverage for an OTC agent OTC under the generic (first) tier of their commercial that they will then have to purchase out-of-pocket? pharmacy benefit. Some of these directors also intend to I think that there are only 2 available options to cover Prilosec OTC for their Medicare Part D enrollees when the prescription drug benefit takes effect next year.
• Option 1 is to add an OTC tier to the formulary: at least These pharmacy directors report significant savings one OTC agent from each therapeutic class for which from providing coverage for the OTC product and, con- OTCs are available could be covered at a lower co- trary to previous policies, tout not only the ease of ad- payment. This provides equal treatment of all drug ministering the program but also the efficiency of their classes and diseases with OTC options, thereby avoid- step-edit protocols when OTC “prescriptions” are in- ing a situation in which claims of discrimination are cluded in the database. Interestingly, some of the plans that cover Prilosec OTC do not cover the OTC versions • Option 2 is to exclude OTC agents from the insured of any other medications in the pharmacy benefit, which “prescription drug benefit.” Unless pharmacy direc-tors want to start covering all OTCs, why open thedoor to exceptions that could lead to unwanted, Dr Reissman is president of Rxperts, Inc, a managed care con-sulting firm in Irvine, Calif. You can visit the Rxperts Web site at 334 DRUG BENEFIT TRENDS August 2005

Source: http://www.rxperts.net/document/0508DBT200247IDM.lay.pdf

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