1. Top Tips for Reducing Your
Pharmaceuticals Budget
Jeffrey E. Keller MD

2. Objectives
 Understand pharmaceutical pricing, including
Acquisition Cost plus, Fill fees, Medicaid
pricing and AWP.
 Understand how to develop and maintain an
appropriate formulary.
 Understand how an OTC Commissary works.

3. How Are You Doing Now?
 Calculate pharmacy costs per inmate per
day.
 <$0.50 per inmate per day = Excellent!
 $0.50-$1.00 per inmate per day = OK!
 $1.00-$1.50 per inmate per day = Average
 >$1.50 per inmate per day = Problem!

4. Rule Number One
Know how much everything costs!

5. Know the price of medications
Esterified Estrogen (Menest) $32.44
Conjugated estrogen (Premarin) $57.44
Estropipate (Ogen) $5.99
Estradiol (Estrace) $4.50

6. Pill Size Comparison

7. Generic Price Drops
 Ittakes approximately two years after a drug
goes generic for the price to drop to low price
status.
 Lamotrogene (Lamictal)
 What drugs went generic last year?

8. New Generic Drugs
 Levetiracem (Keppra)
 Levofloxacin (Levaquin)
 Losartin (Cozaar)
 Zonisamide (Zonagram)
 Ceftriazone (Rocephin)

9. Reverse Generic Examples
 AlbuterolMDI
 Colchicine

10. Understand Pharmacy Pricing
 Average Wholesale Price (AWP)
 FUL (Federal Upper Limit)
 MAC (Maximum Allowable Cost)
 Acquisition Cost Plus

11. AWP—Average Wholesale Price
 AWP is not an average!
 AWP is not wholesale!
 AWP is not the price you want to pay!

12. HCFA Prices
 Federal Upper Limit (FUL)
 Maximum Allowable Cost (MAC)

13. MAC Price Lists
 CIPROFLOXACIN 500MG TAB ER CIPRO XR 07/05/2011
9.41248
 CIPROFLOXACIN HCL 100 MG TAB 07/05/2011 3.00066
 CIPROFLOXACIN HCL 250 MG TAB CIPRO 07/05/2011 0.20731
 CIPROFLOXACIN HCL 500 MG TAB CIPRO 07/05/2011 0.21659
 CIPROFLOXACIN HCL 750 MG TAB CIPRO 07/05/2011 0.26908
 CITALOPRAM 10 MG/5 ML SOLN CELEXA 07/05/2011 0.17737
 CITALOPRAM HBR 10 MG TAB CELEXA 07/05/2011 0.04710
 CITALOPRAM HBR 20 MG TAB CELEXA 07/05/2011 0.05036
 CITALOPRAM HBR 40 MG TAB CELEXA 07/05/2011 0.06135

14. Compare Prices to Medicaid MAC
 Ifyou are paying more than MAC, negotiate
lower prices.

15. Acquisition Price Plus
 Prices fluctuate day to day.
 Set routine to spot check prices

16. Fill Fees
 Fee pharmacy charges for filling prescription
 Should not be over $5.00
 Often the most important part of fee

17. Fill Fees
 Cost of Prescription for 1 HCTZ tablet:
– $0.01 + $4.00 = $4.01
 Cost of 30 HCTZ tablets
– $0.30 + $4.00 = $4.30

18. Tips for reducing fill fees
 50mg po qAM, 100mg po qPM
– TWO fill fees
 50mg one po qAM and 2 po qPM
– ONE fill fee

19. Wastage
 Opened meds cannot legally be reused
 Source of significant waste

20. Tips for Reducing Wastage
 Institute
dosage changes after current
month’s prescription finishes

21. Check Pharmacy Bill
 Mistakescommon
 $44.77? Or $4.77?

22. Formulary
Formularies are the Community Standard
of Care
Formularies, properly done, do NOT
restrict access to appropriate medicine

23. Formulary
 Consider a formulary a “Pre-Approved
Medication list”
 If a medication is not on the formulary, that
does NOT mean you cannot prescribe it.
 It means you have to get approval first.
 Reason could be price. Or not.

24. Formulary--Price
 Should you use Nexium? Or Omeprazole?

25. Formulary--Convenience
 Bupropion? Or Bupropion SR?

26. Formulary—Controlled Drugs
 Ultram
 Ambien
 Soma

27. Formulary
 Yes-No
 $-$$-$$$-$$$$-$$$$$

28. OTC Commissary
 Compareaccess to OTC medications in the
community with inside corrections

29. OTC commissary
 What is the Time Cost to the medical staff of
dealing with OTC requests?

30. OTC Commissary
 OTC Commissary MUST be cheaper for the
inmate than going through sick call.

31. OTC Commissary
 OTC Meds inappropriate for corrections
 Dextromethorphan
 Ephedrine, pseudoephedrine
 Ex-Lax

32. OTC Commissary
 How to handle Indigency
 It still may be cheaper to give indigent
inmates OTC medications.

33. OTC Commissary Examples
 Pain Relievers—Ibuprofen
 Skin Meds—Antifungal, steroid cream
 Acne meds—Stridex, Benzoyl
 Stomache—Ranitidine, omeprazole
 Constipation—Fiber, colace

34. OTC Commissary Examples
 Dietsupplements—Vitamins, lactaid
 Cold and flu—cough drops, loratidine
 Eyes—allergy eye drops
 Psoriasis meds—coal tar

35. Special Cases
 Psychiatric
Medications
 May be 40-60% of your total pharmacy bill

36. Psychiatric Medications
 Seroquel 400mg- $417.02
 600mg- $623.75
 Zyprexa 10mg- $455.61
 15mg- $681.64
 Risperdal 2mg- $6.25
 4mg- $7.83
 Prolixin 5mg- $5.86
 10mg- $6.38
 Haldol 5mg- $6.00
 10mg- $20.15

37. Psychiatric Medications
 Polypharmacy
 Jailvs outside considerations
 Fluidity of treatment
 Drug abuse

38. HIV Hepatitis C
 Treatment algorhythm
 Off-on treatment worse than no treatment at
all

39. Treatment Guidelines
 Clinical
Criteria designed to avoid
unnecessary medication prescriptions

40. CDC Recommendations
Pharyngitis
Four Clinical Criteria
1. Fever
2. Exudate
3. Lymphadenopathy
4. NO cough

41. CDC Recommendations
Sinusitis
1. Symptoms for more than 7 days.
2. Pain or tenderness of face or teeth
3. Purulent nasal discharge.
4. Moderate to severe symptoms.

42. CDC Recommendations
Bronchitis
No Pneumonia—No Antibiotics
1. No Fever
2. No tachypnea
3. No asymmetric crackles

43. SSRI Dosing
 For most drugs (SSRIs), raising the dose beyond the usual
therapeutic range does not speed up response but rather
causes greater severity of side effects (TREATMENTS OF
PSYCHIATRIC DISORDERS - 3rd Ed.)
 For sertraline, the dose is 50 mg once daily for almost all
patients (Cecil Textbook of Medicine, 21st ed).
 For fluoxetine, it is well established that doses higher than 20
mg per day do not produce a better therapeutic response in
most patients (Schweizer et al 1990).

44. SSRI Dosing
 The established minimum effective dose of
paroxetine is 20 mg per day. Doses higher than 20
mg per day have not been documented to improve
percentage of response or response rate (Grimsley
1992)
 There is little evidence that total daily doses of
fluvoxamine greater than 150 mg provide added
efficacy.

45. Atypical Antipsychotics vs. Traditional
Antipsychotics
 Atypical Antipsychotics in the  No difference in symptom
Treatment of Schizophrenia: reduction if conventional dose is
Systematic Overview and Meta- less than 12mg per day.
regression Analysis. Geddes,  Atypicals do cause less extra-
J. and Bebbington, P. pyramidal symptoms, but the
 BMJ 2000; 321: 1371-1376. overall tolerability is identical
 Meta-analysis of 52 between groups.
Randomized trials comparing  “There is no clear evidence that
atypical antipsychotics with atypical antipsychotics are more
conventional antipsychotics effective or are better tolerated
than conventional
antipsychotics.”

46. The Best of the Best
Information Sources
1. Primary Care Medical Abstracts
2. The Oregon Drug Utilization Review
Newsletter
3. The Prescriber’s Letter