Curtiss Frederic R
JMCP, 100 North Pitt Street, Alexandira, VA 22314, USA.
J Manag Care Pharm. 2006 Sep;12(7):570-7. doi: 10.18553/jmcp.2006.12.7.570.
Pharmacy benefits have historically excluded injectable drugs, resulting in coverage of injectable drugs under the medical benefit. High-cost biologics and other new drug therapies are often injectables and therefore have not presented cost threats to pharmacy benefits. The U.S. Food and Drug Administration approval of capecitabine, an oral form of fluorouracil, in 1998, and imatinib mesylate in oral dose form for chronic myeloid leukemia, in 2001, signaled a new period in budget forecasting for pharmacy benefits, particularly for small, self-insured employers for whom a drug with a cost of 25,000 dollars per year of therapy for 1 patient could increase total pharmacy benefit costs by 10% or more.
To quantify the actual relative costs of the oral chemotherapy drugs in pharmacy benefits in 2006 and identify the history of spending on oral chemotherapy drugs relative to total pharmacy benefit spending for small, self-insured employers over the 4.5 years through May 2006.
Administrative pharmacy claims from the database of a pharmacy benefits manager (PBM) for approximately 500,000 members of small, self-insured employer plans were used to calculate the net plan cost of oral chemotherapy drugs relative to total drug benefit costs for the period January 1, 2002, through May 31, 2006. Current costs for oral chemotherapy drugs for small employers were compared with an insured health plan of approximately the same number of members for dates of service January 1, 2006, through May 31, 2006.
This descriptive analysis found that oral chemotherapy drugs represented 0.27% of total drug benefit costs, or approximately 0.08 dollars per member per month (PMPM) for small, self-insured employers in 2002, rising linearly to 0.73%, or approximately 0.24 dollars PMPM in the first 5 months of 2006. Members in pharmacy benefit plans sponsored by small employers paid an average 6.9% cost share for oral chemotherapy drugs in 2006, nearly identical to the average 8.5% paid by members of an insured health plan of similar size in total membership, versus 26.9% average cost share for all drugs. Imatinib mesylate accounted for 45% of total spending on oral chemotherapy agents in 2002 versus 40% in 2006.
Spending on oral chemotherapy drugs as a proportion of total pharmacy benefit costs has more than doubled, from about 0.3% in 2002 to 0.7% in 2006. For small, self-insured employers, this represents a nearly 3-fold increase in spending, from about 0.08 dollars PMPM in 2002 to about 0.24 dollars PMPM in 2006.
从历史上看，药品福利一直将注射用药物排除在外，导致注射用药物由医疗福利覆盖。高成本的生物制剂和其他新型药物疗法通常为注射剂，因此并未对药品福利构成成本威胁。1998年美国食品药品监督管理局批准了口服氟尿嘧啶制剂卡培他滨，以及2001年批准了用于慢性粒细胞白血病的口服剂型甲磺酸伊马替尼，这标志着药品福利预算预测进入了一个新阶段，特别是对于小型的自我投保雇主而言，一种每年治疗一名患者费用达25,000美元的药物可能会使药品福利总成本增加10%或更多。
量化2006年口服化疗药物在药品福利中的实际相对成本，并确定在截至2006年5月的4.5年期间，小型自我投保雇主在口服化疗药物方面的支出相对于药品福利总支出的历史情况。
利用一家药品福利管理机构（PBM）数据库中约500,000名小型自我投保雇主计划成员的药品管理索赔数据，计算2002年1月1日至2006年5月31日期间口服化疗药物相对于药品福利总成本的净计划成本。将小型雇主口服化疗药物的当前成本与2006年1月1日至2006年5月31日服务日期的成员数量大致相同的参保健康计划进行比较。
这项描述性分析发现，口服化疗药物占药品福利总成本的0.27%，即2002年小型自我投保雇主每名成员每月约0.08美元（PMPM），到2006年前5个月线性上升至0.73%，即约0.24美元PMPM。2006年，由小型雇主赞助的药品福利计划中的成员为口服化疗药物支付的平均成本分担为6.9%，与规模类似的参保健康计划中成员在总成员数中支付的平均8.5%几乎相同，而所有药物的平均成本分担为26.9%。2002年甲磺酸伊马替尼占口服化疗药物总支出的45%，2006年为40%。
口服化疗药物支出占药品福利总成本的比例增加了一倍多，从2002年的约0.3%增至2006年的0.7%。对于小型自我投保雇主而言，这意味着支出增加了近3倍，从2002年的约0.08美元PMPM增至2006年的约0.24美元PMPM。
