Any managed care pharmacists here?

[Sparda29]

Do you guys monitor retail pharmacy claims and then adjust formularies based on if certain drugs are being paid out way too much?

For example, we used to get a ****-ton of prescriptions for Lidocaine 5% ointment, which would get $300-400 profit/script, and now we're getting a lot of messages for drug not covered or prior authorization needed.

Same thing for Vanos generic cream, calipotriene cream and ointment, diclofenac 3% gel.

Example: the pain management doc around here had every single one of his patients on Lidocaine 5% ointment #100 grams a month and Diclofenac 3% gel #100 grams a month on top of the other drugs.

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[PromisedNeverland]

 

[297point1]

To Sparda: They'll definitely slap a PA or quantity limits on medications that are generating more way expenses than they expect (and can't figure out why). Dropping it from the formulary may or may not happen, but they will certainly make it more difficult to obtain.

Welcome back, btw...saw this on Jalopnik a few days ago and thought of you: http://jalopnik.com/man-unsurprisingly-crashes-and-is-seriously-injured-in-1789557341

??? He was the OP.

 

[Sparda29]

To Sparda: They'll definitely slap a PA or quantity limits on medications that are generating more way expenses than they expect (and can't figure out why). Dropping it from the formulary may or may not happen, but they will certainly make it more difficult to obtain.

Welcome back, btw...saw this on Jalopnik a few days ago and thought of you: http://jalopnik.com/man-unsurprisingly-crashes-and-is-seriously-injured-in-1789557341


??? He was the OP.

Ugh, I figured they'd do that as soon as they figured out people are making too much money. Have any of you ever heard of these "medication packs" with absurdly high AWPs? Example, there's this thing called Inflammacin pack that the owner found out about. He told his doctor friends about it. When you open it up, it contains a 60 count bottle of diclofenac 75 mg tablets and a 8 ounce bottle of capsaicin cream. Cost is about $1000 and the insurances pay out about $5000. It goes through if you put an override code in and gets slapped with an audit but they allow it once they see the paperwork.

PS: I still speed but not with a cell phone in my hand.

 

[297point1]

Have any of you ever heard of these "medication packs" with absurdly high AWPs?

Sure. Back in the day, it was Prevpac (Prevacid, Biaxin, and Amoxil) for treating H. pylori infections. [I think I remember a combo pack using Zantac and bismuth as well.] Prevpac had a higher AWP than the individual components dispensed separately; most insurers in my area put the kibosh on that. However, it was nowhere near the percentage mark-up or scale of what you just described for Inflammacin- and all of those components are generic!