Three-tier formularies don't increase hospital visits

March 1, 2002

Pharmaceutical Representative

Adding a third, higher-cost pharmacy benefit co-payment level did not result in higher numbers of emergency room visits or inpatient hospitalizations.

Adding a third, higher-cost pharmacy benefit co-payment level did not result in higher numbers of emergency room visits or inpatient hospitalizations, according to the results of a study conducted by St. Louis-based pharmacy benefit manager Express Scripts Inc.

The study analyzed medical and prescription claims for more than 20,000 enrollees in a preferred-provider organization who were continuously eligible from January 1, 1997 through November 30, 1999. The sample sizes were 6,881 and 13,279 for the three-tier intervention and non-three-tier comparison groups, respectively.

"The study's results suggest that three-tier prescription benefits can control drug costs without any evidence of affecting use of other medical resources in the year following implementation," said Brenda Motheral, principal author of the study and senior director of outcomes research for Express Scripts.

Modestly slower growth

According to Motheral, the intervention group in which a three-tier co-pay was implemented experienced modestly slower growth in prescription utilization, higher co-payment outlays by members and considerably reduced net cost for the payer.

"The modestly lower pharmaceutical use in the intervention group provides little reason to expect any longer-term impact," said Motheral. However, she said that a statistically significant decrease in the rate of prescription continuation among estrogen users in the three-tier intervention group warrants further study.

The lower prescription continuation rate among estrogen users could have been caused by factors other than the institution of the three-tier co-payment structure. Only 17% of the intervention group's pre-study period estrogen claims were for medications that were placed on tier three at the start of the study period, compared with 29% for antihypertensives, 20% for oral contraceptives and 11% for antihyperlipidemics. There was no significant decrease in prescription rates among users of antihypertensives, antihyperlipidemics or oral contraceptives. PR

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