Cox-2 inhibitors, Celebrex (celecoxib) and Vioxx (rofecoxib) were first introduced in 1999. Cox-2 inhibitors are nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are used to treat arthritis and other painful conditions.

The use of the Cox-2 drugs has grown dramatically over the last two years. The purported advantage of Cox-2 drugs is that they reduce the incidence of ulcers that may occur when patients take other NSAIDs. Approximately 4% of the population is believed to be at high risk for the development of ulcers. This includes patients using steroids, with a prior history of gastrointestinal disease, and the elderly.

Although the reduction of the incidence of ulcers is a positive benefit, many patients using Cox-2 inhibitors are not at risk for developing ulcers. This is an important issue since Cox-2 drugs are much more expensive than the older NSAIDs. In fact, the introduction of Cox-2s has resulted in cost increases of 25% to 40% for the NSAID class.

Pharmacy benefit managers have struggled with a way to make these new drugs available to patients at the highest risk for ulcers while restricting access to patients who are able to take older NSAIDs. Some of the options used to manage Cox-2s include identifying these drugs as non-preferred (requiring a higher copayment), requiring the use of older drugs before these drugs are covered (step therapy), requiring a clinical review (prior authorization), or not covering these drugs at all.

In his presentation at the Academy of Managed Care Pharmacy conference in October 2000, Elgene Jacobs, PhD, discussed how the Oklahoma Employees Group Insurance (OEGI) Program manages Cox-2 utilization. He explained that in the year before Cox-2s were introduced, OEGIs cost per member per month (PMPM) for NSAIDs was approximately $1. By the second quarter of 1999, after Cox-2 introduction, the NSAID PMPM grew to $2.18. At this point, Cox-2 accounted for 30% of the NSAID prescriptions and 60% of the NSAID prescription dollars.

To manage Cox-2 and other high-cost drug use, OEGI implemented a "Therapeutic Buy-Up" program. In a Buy-Up program, the payor identifies preferred products in each therapeutic class. If a patient wants to use a non-preferred product, they must pay the difference between the cost of the non-preferred product and the preferred product, plus the copayment. If the patient can prove a clinical need, the patient can receive the prescription for the usual copayment.

In the third quarter of 1999, Cox-2s were added to the OEGI Buy-Up program as non-preferred products. In order to receive a Cox-2 prescription, the patients are required to pay a larger portion of the cost. By the fourth quarter of 1999, PMPM costs for NSAIDs decreased from $2.18 to $1.62. Cox-2 prescriptions had increased to 36% of NSAID prescriptions, but were still holding at 60% of NSAID Rx dollars. This reduction in the PMPM cost for NSAIDs was achieved by requiring the patient to assume a higher share of the cost of these drugs, not by preventing access to these drugs.

Many different mechanisms are available for managing the use of individual drugs. The method used by OEGI encourages patients to use the most cost-effective drug by requiring them to pay the non-preferred drug cost difference. Talk to your PBM about recommendations for managing Cox-2 inhibitors, as well as other therapeutic classes.
 
 

Source:

Elgene W. Jacobs, PhD, The Impact of Benefit Design: An Overview of Cost Trends and Targeted Classes: Cox-2 & GI Medications; Academy of Managed Care Pharmacy presentation, October 5, 2000.