Survey shows modest changes in NSAH coverage

Plan sponsors are making incremental changes in the coverage of non-sedating antihistamine (NSAH) drugs in the wake of the new over-the-counter (OTC) status of Claritin® (loratidine).

The Pharmacy Benefit Management Institute conducted telephone interviews with 20 companies to learn how plan sponsors and their pharmacy benefits managers (PBMs) are managing the NSAH class now that there is an OTC alternative. The plan sponsors surveyed represent 837,782 commercially insured active employees and retirees, with groups ranging in size from 175 to 183,322 members.

Interviewed in late January, the plan sponsors have a variety of perspectives on the best clinical and economic strategies to employ to manage this class of drugs.

Class Strategies
All of the plan sponsors surveyed were aware of the status change and, with one exception, exclude OTC Claritin. The majority of plan sponsors continue to cover the NSAH class. The prescription drugs in this class are Allegra®, Clarinex® and Zyrtec®. Four plan sponsors are evaluating excluding the entire class as one cost-savings approach.

Eliminating coverage of prescription NSAHs "is on the schedule to discuss in the next couple of weeks, but it hasn't been as urgent for us as for some other employers," reported one plan sponsor. Another plan sponsor is adopting a wait-and-see approach:

"We're looking at it, too. I'm going to be a little cautious here. We're not going to be the first to step off that boat. I'm going to let a couple of the other employers do it and see how it plays out, what kind of kickback they get from their employees, and see how effective it is."

The seasonality of allergic rhinitis in many parts of the country allows many plan sponsors to delay making a decision. As one survey respondent commented:

"I still think it's a little too soon, because this time of the year we're not seeing anything when it comes to allergies. But come the spring and fall, I think we'll see more activity and possibly if they're [PBM] going to make recommendations or adjustments, they will be provided at that time."

Many plan sponsors are switching the prescription NSAHs to nonpreferred or higher tiers as indicated by these respondent comments:

"We'll be discussing moving all others to third tier at our May meeting. We're waiting for Prilosec® to go OTC so we can do the same thing."

"Allegra® has been a formulary preferred drug all along, whereas Claritin® was not and Clarinex® will not be. If people flock to Allegra®, they'll probably make that nonpreferred as well. I did hear from one HMO they were going to make all Claritin® substitutes nonpreferred."

Another management option is to use prior authorization to control access.

"We may go to prior authorization on those over the coming year," said a plan sponsor. Another plan sponsor covers a 30-day supply of an NSAH during a 180-day period. Following this period, a prior authorization is required.

With the movement of the prescription NSAHs to nonpreferred status or third tiers, reimbursing for OTC forms of loratidine may be cost-effective for plan sponsors. Working within its state's insurance guidelines, one plan sponsor is covering the OTC alternatives. "We decided to cover the OTC to save costs," reported the plan sponsor. "We've been receiving a positive response from both our active employees and retirees."

PBM Recommendations
Only half of the plan sponsors surveyed reported discussing the issue with their PBM or receiving specific recommendations for changes in plan design or cost sharing arrangements. Few plan sponsors received savings projections for the class for 2003. One PBM "used an amount of from one half of a percent to one percent of our total drug costs" to project the savings associated with excluding OTC Claritin®.

Our PBM has "not said anything to us about how to handle it," reported a plan sponsor. "Obviously Claritin® was a very expensive drug there for a while so this will hopefully help some of our cost savings I would think, but they [PBM] haven't given any recommendation yet."

One PBM did make changes in formulary status for the remaining prescription NSAHs. "The recommendationwas that a couple of other drugs would now be nonpreferred," said the plan sponsor. "[L]ike Allegra D®, they moved that into a different category where at one time it was considered preferred, now it is nonpreferred so the copay is higher than it used to be."

"Because we are fully insured and our drug plan is linked to our medical plan, the PBM didn't come to us suggesting a specific approach," commented one plan sponsor. "It was more that they will no longer cover Claritin®. They will monitor the use of the other similar prescription drugs."

Additional Resources
In addition to PBMs, plan sponsors are using other resources in their decision-making process about NSAHs. Respondents use consultants, Washington Business Group on Health, Employee Benefits Foundation International, other companies, research studies, and trade journals focusing on drug benefits.

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