Week 11: More managed Care

Question 1

Prior Authorization

Answer 1

-need to try lower cost meds first
-w/o = healthcare cost inc

Question 2

Number one reason for denying PAs

Answer 2

-denying for not enough information
-50% come back appealed

Question 3

What percentage of ER trips for airway disorder that never had inhaler

Answer 3

-25%
-those using the system are costing the system

Question 4

How does managed care really work

Answer 4

-it’s not about the money but it’s always about the money

Question 5

Indiana SUPDL

Answer 5

-state of Indiana formulary
-decide what’s covered, what’s PA, etc

Question 6

Impact of pandemic

Answer 6

-costs low during bc no one was seeing doctor
-costs up as ppl went back to doctor and find out about underlying condition from past 4 years

Question 7

GLP utilization

Answer 7

-utilixation gone down bc manufacturers can’t make enough
-more expensive in Indiana
-
-Indiana doesn’t cover GLP for weight loss?

Question 8

Biosimilar utilization

Answer 8

-biosimilars cheaper
-harder to make pt switch to cheaper rx
-incentives to get dr to switch rx
-Humira for generic abulinamab
-Why does Indiana wanna keep Humira on formulary? PBMs threaten to increase prices of other prices if they drop humira

Question 9

Weight loss medications

Answer 9

-not covered in Indiana but sleep apnea and all other indications are

Question 10

Specialty meds

Answer 10

-represent >40% of spending
-trending up to more than half of expenses

Question 11

Indiana looking to make certain PBMs illegal

Answer 11

-making illegal for PBMs to own retail pharmacies (like CVS) in Indiana
-but then may have to go to PBMs that are more restrictive (cant control costs)

Question 12

Top therapies in Indiana by cost

Answer 12

1. Diabetes (would be even more $$ if GLP-1s weren/t shorted)
2. Behavioral Health
3. Inflammatory (Humira)
4. Asthma and COPD (corralin)
5. Dermatologic
6. Infectious disease (HIV)
7. Pain (migraines)

-more GI in michigan

Question 13

Top specialty drugs

Answer 13

-Humira (inflammatory) has biosimilar
-Dupixent (dermatitis/asthma)
-Norditropin (growth hormone)
-Synagis
-Skyrizzi and RInvoke up over Humira

Question 14

Humira

Answer 14

-prob getting removed from formulary
-gonna change to skyrizzi and rinvoke
-trying to get pt on biosimilar now to save money before change

Question 15

Top non specialty drugs

Answer 15

-Dexcom
-Vyvanse
-ADHD meds

Question 16

Top 8 drugs

Answer 16

1. Humira
2. Ozempic
3. Dupixent
4. Vraylar
5. Biktarvy
6. Cosentyx
7. Dexcom
8. Vyvanse

-top 25 drugs cost >$200million