How to eliminate prescription waste

Concerns about the rising cost burden of prescription medications represent a rare area of agreement across the healthcare sector.  

In a recent study of plan sponsors, 93% said high drug prices are a threat to the affordability of employer-provided coverage.¹ High-cost drugs also present affordability concerns for patients. Despite over 90% of the United States population having some form of health insurance, medical debt remains a persistent problem.²

High-cost drugs that offer little to no added clinical value over existing, less expensive alternatives are one of the leading drivers of rising costs. These drugs continue to enter the market and can cost hundreds as times as much as clinically appropriate alternatives. 

The Optum Rx Vigilant Drug Program addresses the challenge caused by these high-cost, low-value drugs. The program uses advanced analytics and dedicated market surveillance to identify these drugs. It then removes wasteful spending by shifting utilization to lower-cost drugs through exclusions. 

How it works

The Vigilant Drug Program gives you flexibility to limit access to certain categories of drugs, including new ones whose clinical and financial value are not yet established. The Vigilant Drug Program is modular and makes use of several clinical quality and cost-savings strategies to achieve robust overall per member per month (PMPM) savings.

The program includes clinical quality strategies to drive clinical appropriateness and cost savings.

• New drugs to market strategy — Temporarily excludes newly launched products until they can be formally reviewed by the Optum Rx National Pharmacy & Therapeutics (P&T) Committee. This program is a standard component of our Premium Formulary. This helps minimize member disruption and decrease financial risk until P&T review is completed.
• Clinical duplicates strategy — Excludes newer, more costly medications that offer little to no clinical advantage over existing medications with similar chemical composition and possible generic options. Examples include unique dosage forms, combinations of two or more available medications, unique strengths, certain delivery devices and multiple product kits/packages.
• Non-essential strategy — Excludes select high-cost, non-FDA-approved products or those deemed unnecessary. Encourages use of lower-cost, FDA-approved options with established safety and effectiveness for the same condition(s). 

The program also includes cost-saving strategies to promote the use of clinically equivalent, lower-cost options.

• High-cost brands with generics — Excludes select high-cost brand products when a lower-cost, therapeutically interchangeable generic product is available. 
• High-cost generics — Excludes high-cost generics when lower-cost alternatives are available with the same active ingredients or belong to the same drug class. 

The Vigilant Drug Program in action

Of the many drugs excluded by the Optum Rx Vigilant Drug Program, few demonstrate the potential for savings more clearly than Pennsaid®, an anti-inflammatory drug applied topically to treat the pain of osteoarthritis of the knee. Pennsaid costs eight times more than a clinically appropriate generic alternative.

Another prime example of the drugs targeted by the program is Vimovo®, a brand oral medication used to treat symptoms of osteoarthritis and rheumatoid arthritis. Vimovo contains a combination of a nonsteroidal anti-inflammatory drug (NSAID) and a proton pump inhibitor (PPI) and has an average wholesale price (AWP) of $2,978 per 30 days. In comparison, clinically appropriate alternative naproxen, an NSAID, costs $68 AWP per 30 days. In addition, a complementary and alternative PPI, such as pantoprazole costs $180 AWP.⁵

Often, several high-cost, low-value drugs will flood a single drug class. This is the case with prescription prenatal vitamins that include similar combinations of vitamins and minerals as clinically comparable generic alternatives. The Vigilant Drug Program has identified low-cost replacements for several drugs in this class including Jenliva, Ziphex and PreGenna. These products can cost as much as $2,257 (AWP) per prescription, compared with $46 for alternatives.⁶ This helps not only clients but also pregnant women who may have chosen to forego these products altogether due to cost concerns.

Likewise, the Vigilant Drug Program has identified a similar trend of high-priced prescription wound dressings. These products are used to manage wounds and scars resulting from burns, surgical procedures or other trauma. Consider ScarcinPad. Despite having similar ingredients as over the counter (OTC) and lower-cost generic products, this product can cost as much as $5,726 ― compared with $12 for alternatives.⁷

A commitment to controlling costs

Optum Rx is unique in the resources it has dedicated to identifying and mitigating these types of wasteful spending.

“As drug costs continue to rise, proactive strategies such as the Vigilant Drug Program will only become more crucial,” says Savitha Vivian, senior vice president of clinical services, Optum Rx. “By empowering plan sponsors to combat the troubling trend of drug pricing misconduct, we are helping safeguard critical pharmacy benefit resources for drug therapies that provide meaningful clinical value.”

The Vigilant Drug Program is a prime example of how Optum Rx is protecting clients and members against rising costs. To learn more, please reach out to your Optum Rx representative.