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The
2007 survey reinstates and expands several research questions on drug
inclusions, exclusions, and utilization management tools. Because
there is so much new data being captured, this will serve as baseline
data for future reports.
What Employers are Excluding ... and Covering
A significant majority of employers exclude coverage of experimental
and investigational drugs, hair-growth treatment, over-the-counter
(OTC) drugs and weight loss/gain products (see Table 40). Most employers
do cover diabetes supplies and sleep disorder drugs.
Less than half of employers cover these drugs with no limitations.
Employers use a range of approaches to manage drug classes, including
prior authorization and days supply limits (see Table 41).
The employers using “other” approaches use a variety of
ways to limit the amount of money spent on these drugs. These approaches
range from out-of-pocket caps and quantity limits, to age limits or
prior authorization protocols that involve medical providers.
Prilosec® is the most widely covered OTC drug, covered by 83.9
percent of the employers who responded. There also is coverage of
Claritin® by 79.3 percent of employers. Employers use prior authorization
and step therapy to manage the coverage of these products.
Only 43.7 percent of employers cover Nexium®, a brand-name proton
pump inhibitor for which there are OTC alternatives, with no restrictions.
Meanwhile, 40.2 percent exclude it from coverage altogether.
Popular
Utilization Management Tools
Employers are using a broad range of utilization management tools
for all diseases. Quantity limits are used by 76.4 percent of employers
across all disease states, followed by refill-too-soon supply limits,
used by 75.8 percent of employers. Only 3.1 percent of employers use
generic sampling for all diseases, but 60 percent of employers use
the tool to manage high cholesterol.
The use of each tool varies with the five diseases selected for this
survey. We selected these diseases to better understand how employers
are managing the drug benefit for conditions that are commonly treated
with drug therapies.
The mix of utilization management tools used varies by disease or
condition. More employers are using more tools to manage diabetes
than asthma, depression, high blood pressure, and high cholesterol.
The refill-too-soon supply limit is used by about 84 percent of all
employers in all five disease states.
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