2009 Workers' Compensation
Drug Trend Report
An analysis of trend and a forecast for the future Express Scripts, Inc.
One Express WaySt. Louis, Missouri 63121 Published April 2010 Emily Cox, PhD, RPh Yakov Svirnovskiy Jennifer Kaburick, RN Ruth Martinez, RPh The authors would like to thank the analysts, researchers, reviewers and sponsors for the 2009 Workers' Compensation Drug Trend Report. We also recognize generous assistance from individuals throughout the Express Scripts organization, including the Clinical, Creative Management Services, Product Management and Research teams.
The workers' compensation industry is ever-changing, from statute revisions to new approaches for
managing disability and medical costs. The prescription-drug landscape for workers' compensation is
just as dynamic.
During 2009, major events included the: • Revision of pharmacy fee schedules by For 2009, overall trend for Express Scripts Workers' Compensation clients was 8.4%1. Increases in both utilization (6%) and cost per prescription • Updating of reporting requirements by (2%) contributed to the rise. However, unlike 2008 when cost per prescription was the main driver of trend, utilization was the primary factor in 2009. • Continued progress toward the National Increased use of nonformulary medications — Council on Compensation Insurance (NCCI) such as medications to control cholesterol and medical data call high blood pressure — contributed to increased • Significant revisions made to pricing utilization. Because these classes of medications methodologies for Medicare Set- are generally not used for most occupational Asides* (MSAs) by the Centers for injuries and job-related illnesses, they are not Medicare & Medicaid Services (CMS) included on the Express Scripts standard workers' compensation formulary. Therefore, review by our • Continued discussion regarding a closed clients is required to determine if these medications formulary in Texas can be approved. If the client approves, then the medications can be dispensed by the pharmacy. • Settlement of a class-action lawsuit that resulted in a reduction of pharmacy benchmark Exhibit 1
prices on Sept. 26, 2009, with plans for the average wholesale price (AWP) standard to be Components of Drug Trend
replaced by the end of 2011 As these types of market forces emerge, pharmacy- cost trends are impacted, creating a new set of Year Overal Prescription Utilization
challenges for workers' compensation payers. This 2008 8.9%
results in increased attention to the cost and use of prescription drugs in workers' compensation.
2009 8.4%
* Medicare Set-Asides are offered through Express Scripts MSA, LLC.
1 Drug trend was calculated using only Express Scripts clients with stable membership (less than 50% change in user volume between 2008 and 2009). Therefore, data for the 2009 Drug Trend Report did not include MSC legacy clients.
2 Common drugs are those prescribed in both 2008 and 2009.
3 New drugs are those prescribed in 2009, but not in 2008.
Express Scripts 2009 Workers' Compensation Drug Trend Report Workers' Compensation
Therapy Class review
For workers' compensation, little change was
mainstays for relieving pain that ranges from acute seen in the top therapy classes from year to year. to chronic and from mild to severe. In addition In 2009, the top five therapy classes, as ranked to their primary uses, many anticonvulsants and by per user per year cost, were the same as they antidepressants have indications to treat pain were in 2008. A sixth class, dermatologicals, was and associated complaints that commonly affect added because it represented a significant part injured workers. Skeletal muscle relaxants include of trend for the year. Together, the top six classes prescription drugs used to relieve spasms that accounted for over 76.8% of 2009 total cost trend often accompany muscle overuse or damage. for Express Scripts Workers' Compensation clients. The final class, dermatologicals, includes topical products that are applied to treat many conditions, Due to the nature of most work-related injuries, all six top classes manage pain either directly or indirectly. Narcotic analgesics and NSAIDs are Exhibit 2
Components of Trend for the Top Six Therapy Classes Ranked by 2009 Per User Per Year Cost
% Total Cost
% New Drugs
Skeletal Muscle Relaxants
Express Scripts 2009 Workers' Compensation Drug Trend Report Narcotic Analgesics
As the drug class prescribed most often in workers'
• In 2009, utilization for Actiq® (oral transmucosal compensation, narcotic analgesics treat moderate fentanyl citrate), Fentora® (fentanyl buccal and severe chronic pain. tablet) and fentanyl citrate decreased, which may be attributed to a 2008 settlement with • Typically, as claims age, the cost per the medications' manufacturer related to prescription in the narcotic analgesic therapy the sales and marketing practices of Actiq. class increases for a number of reasons. The media attention may have tempered the Frequently, injured workers progress to prescribing patterns of physicians ordering narcotics from other types of pain medications these medications. when chronic pain persists. Because injured workers often become resistant to the pain- • Embeda™ (morphine extended release relieving effects of narcotic analgesics after and naltrexone), Nucynta™ (tapentadol), taking them for extended periods of time, and Ryzolt™ (tramadol extended release) increasingly higher doses may be needed to were launched in 2009. None of these new control pain adequately. Injured workers may medications are expected to have much effect also move from generics to brands that have on cost or utilization moving forward.
no generic alternatives. A general trend toward earlier use of narcotics and use of narcotics for acute pain may also increase utilization in In addition to relieving seizures that are associated with many head injuries, anticonvulsants are often used to treat nerve pain and other conditions such • As in 2007 and 2008, approximately 40% as fibromyalgia. of total workers' compensation trend for Express Scripts clients was in the narcotic • Although 2009 utilization was up 4.2% in the analgesics class. While the generic anticonvulsants class, total cost trend was combination hydrocodone and acetaminophen down 12.6%, largely due to the introduction was the most utilized medication (accounting of new generics, resulting in an overall trend for 42.5% of the narcotic analgesics utilized), decrease of 8.9%. 28% of spend was due to one brand-name medication, OxyContin® (oxycodone). • In 2009 and late 2008, generics were approved for Depakote® and Depakote® extended release • Generics for OxyContin, which were launched (divalproex sodium), Keppra® (levetiracetam), in 2004, have mostly been removed from Lamictal® (lamotrigine) and Topamax® the market due to patent settlements. Wide (topiramate). Subsequently, utilization for all availability of generics for OxyContin is not the affected brands fell at least 50%.
expected again until 2013. • Utilization for the second-ranking medication in the class, gabapentin, was up nearly 10.1%. However, because gabapentin's average cost per prescription was down approximately 28%, the total trend for the medication fell approximately 21%.
Express Scripts 2009 Workers' Compensation Drug Trend Report • Lyrica® (pregabalin), the class leader in both • Generics for the number two medication, per user per year cost ($61.06) and utilization Effexor XR, should be approved in July 2010. (0.36), will not have generic competition until However, Pristiq® (desvenlafaxine), a follow-on to Effexor XR introduced in 2008, experienced dramatic utilization increases in 2009. • New anticonvulsants (such as Banzel®, Sabril®, Stavzor® and Vimpat®) and new dosage forms skeletal Muscle relaxants
(including Lamictal® ODT™ and Keppra XR™) Skeletal muscle relaxants relieve spasms and had minimal effect on utilization and cost in reduce pain from soft-tissue injuries, such as 2009. However, some of these brand-name sprains. Frequently, prescription drugs in this class medications may gain market share if they are used in combination with narcotic analgesics receive additional approvals or if they prove or NSAIDs since muscle spasms cycle with pain. effective for work-related injuries.
Although they may be used to treat long-term conditions such as cerebral palsy, skeletal muscle relaxants are generally recommended for short-term Depression often accompanies long-term pain. use (usually no longer than eight weeks). For Many antidepressants are also approved to relieve workers' compensation, they are usually prescribed nerve pain, so a single antidepressant may relieve soon after an injury. more than one aspect of an injury. • The skeletal muscle relaxant class includes • Cymbalta® (duloxetine HCI) was by far the a large number of generics; however, the top class leader with a per user per year cost of three spots in per user per year cost are held $47.69. Along with its earlier indications for by the brands Skelaxin® (metaxalone), Amrix® depression, acute treatment for generalized (cyclobenzaprine HCI extended release) and anxiety disorder (GAD), and nerve pain, Soma® (carisoprodol). Cymbalta was approved for fibromyalgia in June 2008, and for maintenance treatment of • Skelaxin costs more than double per user GAD in November 2009. Its multiple indications per year ($32.30) than the second most- make Cymbalta useful for treating several costly medication in the class, Amrix aspects of work-related injuries.
($13.42), primarily due to substantially higher utilization. • Despite decreases in overall trend during 2009, Effexor XR® (venlafaxine HCI) and Lexapro® • Amrix, an extended-release form of the (escitalopram oxalate) held the number two prescription drug cyclobenzaprine, released in and three spots by per user per year cost.
November 2007, quickly made its way to the second spot as ranked by per user per year • Of the top three antidepressants, Cymbalta cost. Although an immediate-release form of was the only medication to experience an cyclobenzaprine is available generically, Amrix increase in both cost and utilization. is formulated for once-daily dosing, which makes it more convenient for the injured worker.
Express Scripts 2009 Workers' Compensation Drug Trend Report NsAIds
Common first-line treatments for mild-to-moderate
• Lidoderm® (lidocaine patch 5%) is an pain associated with acute injuries, NSAIDs are anesthetic patch approved to relieve usually indicated for short-term use. postherpetic neuralgia — the pain caused by shingles. Widely used for many other types of • With 0.40 prescriptions per user per year, pain, it is applied directly to the painful areas generic ibuprofen leads the class in utilization, of skin for up to 12 hours per day. At $68.98 but Celebrex® (celecoxib), the only COX-2 per user per year, Lidoderm accounts for 74% inhibitor on the US market, is close behind of spend in the class. Its utilization rate (0.22 prescriptions per user per year) is more than • The 2009 per user per year cost for Celebrex triple any other drug in the class.
($56.04) is almost 10 times the cost per • A relatively new topical NSAID, Flector® Patch prescription of the next most utilized NSAID, (diclofenac epolamine topical patch), was meloxicam, at $5.83. launched in January 2008 and holds the number two spot in the class by per user per year cost ($14.36). The dermatologicals class includes all prescription drugs applied to the skin, such as creams, • Voltaren® Gel, a topical form of the NSAID ointments and patches. It is a very large and varied diclofenac was also released in early 2008. It class that contains many generics. For workers' rose to third place by per user per year cost in compensation, three brand-name pain products dominate the dermatologicals class: • The total trend in the class resulted almost entirely from a 21.3% increase in utilization, driven by huge jumps for Flector Patch and Voltaren Gel.
Exhibit 3
Top Five Medications Ranked by 2009 Per User Per Year Cost
Average Cost Per Prescription
Narcotic Analgesics Narcotic Analgesics Express Scripts 2009 Workers' Compensation Drug Trend Report MANAgINg Workers' CoMPeNsATIoN
PhArMACy TreNd

Utilization management (UM) is critical for In addition to other clinical programs — like controlling drug trend. However, unlike group formulary edits, Concurrent Drug Utilization Review health — which incorporates UM within the (DUR), and Retrospective DUR — ScriptAlert plan sponsor's benefit plan design and is provides an additional layer of edits. ScriptAlert provided by the pharmacy benefit manager — monitors possible drug-therapy problems and helps workers' compensation clients have the ultimate clients identify potentially inappropriate patterns responsibility to authorize or deny nonformulary of use. Examples of possible misuse are unusual medications. Express Scripts has created narcotic usage, duplicate therapy, excessive therapy programs to help our clients review medication duration, overlapping prescribers, and questionable use and handle claims proactively. Our clinical relevance to injury. ScriptAlert evaluates the pharmacy programs facilitate improved quality need for case management, independent medical of care for injured workers, enhance therapeutic examinations (IMEs), peer-to-peer physician outcomes, and reduce prescription-drug conversations, and other interventions.
expenditures. Our clinical UM programs for workers' compensation include: Pharmacist drug review
With Pharmacist Drug Review (PDRx), one of our
clinical pharmacists reviews an injured worker's Procedures to assure that dispensed medications entire medication file as provided by the client. relate to the injury are primary to any workers' Based on established medical practice guidelines, compensation pharmacy program. Express Scripts the PDRx pharmacist performs an in-depth analysis Prior Authorization process helps adjusters and of the injured worker's therapy and offers a formal, nurses determine whether medications not on written report that details any drug-therapy the standard formulary should be covered. Our problems, proposes alternative drug therapies, and Web-based tool, OASIS, facilitates decision- outlines desired clinical outcomes. PDRx reports making with ease. If a prescription rejects at also include a complete financial breakdown of the point of service, an e-mail notification of an all existing drug therapy and identify potential authorization request waiting on our website cost savings associated with any recommended is automatically sent to the claims adjuster or treatment alternatives. Typically, PDRx assessment case manager. Extensive information about the is reserved for the most clinically challenging medication (supported by, the injured worker's prescription history and other key elements are provided to help with decision- • High-cost medical cases making. The adjuster or nurse can approve or deny • Multiple medication use (polypharmacy) the medication, and the decision is quickly relayed to the pharmacist.
• Complex or multiple diagnoses (for example, catastrophic injuries) Express Scripts 2009 Workers' Compensation Drug Trend Report • Repeated early refill attempts The use of generic medications is a primary factor in controlling drug cost. Express Scripts has a • Anticipated treatment duration greater than long history of leading the Pharmacy Benefit Management (PBM) industry in driving the use • Multiple pharmacies or physicians of generics. In 2009, our Workers' Compensation clients achieved an average generic fill rate (GFR) • Questionable drug therapy relevance to injury of 68.6%, which measures the percentage of total prescriptions dispensed as generic medications. Managing Prescribing Patterns
By adopting clinical programs that address both Another key element in managing prescription single-source and multi-source brand medications utilization is influencing physician prescribing — including the Physician Outreach Program patterns. This is the focus of the clinical programs and Step Therapy — our clients have the ability in Exhibit 4.
to reach GFRs in excess of our book-of-business average. To that end, Express Scripts will soon begin piloting a new long-acting opioid Step Therapy module.
Exhibit 4
Clinical Programs to Manage Prescribing Patterns
Physician Outreach Program (POP) Letters sent to physicians ordering multi-source brands as dispense as written (DAW1) and select single-source brands when effective generic alternatives are available Retrospective DUR Letters sent to physicians, notifying Deter fraud and abuse; increase them of ongoing patterns of potential y safety for injured workers inappropriate medication usage Point-of-sale edit designed to encourage physicians to prescribe a Step 1 medication (usual y a generic) before a higher cost Step 2 brand-name drug Express Scripts 2009 Workers' Compensation Drug Trend Report Channel
Ensuring that prescription drugs are dispensed
network penetration. We are currently engaged in through the appropriate delivery channel is another multiple pilots to test the effects of behavioral key element to managing costs. By increasing the economic principles on Home Delivery conversion use of network pharmacies and Home Delivery from and on prescription ID card utilization. the Express Scripts Pharmacy while reducing the use of third-party billers (TPBs), Express Scripts A Look at What's to Come
clients can successfully reduce their overall drug As we look ahead into 2010 and beyond, supplies spend, while ensuring an efficient and stress-free of generics for OxyContin will continue to diminish experience for the injured worker. as patent settlements delay true generics until 2013. In the meantime, manufacturers continue to develop new abuse-resistant brand products. Express Scripts incorporates a variety of strategies Another factor that will affect pharmacy program to drive network penetration, which we define as costs in workers' compensation will be the US the percentage of billed prescriptions (electronic Food & Drug Administration's (FDA) continued and paper claims) that were filled without TPB work with manufacturers to establish a class-wide involvement at participating pharmacies (including Risk Evaluation and Mitigation Strategy (REMS) Express Scripts pharmacies). Through our First program for long-acting and extended-release Fill program and ID card communications, we fentanyl, hydromorphone, methadone, morphine, proactively educate injured workers on the oxycodone and oxymorphone products. Formal use of participating pharmacies. For those recommendations should be made in 2010 to prescriptions filled out of network (either through reduce the risk of misuse and accidental overdose a nonparticipating pharmacy, or with a TPB), our of these opioids. Among antidepressants the Paper-Bill Conversion process strives to bring future generic to Effexor XR, expected in mid-2010, will be prescriptions back in network. By communicating the first generic serotonin-norepinephrine reuptake with injured workers, TPBs, and our network inhibitor (SNRI). Patent settlements could delay pharmacies regarding the need to utilize the additional Effexor XR generics until mid-2011.
Express Scripts ID card for processing prescriptions online, we have successfully increased network As always, Express Scripts Workers' Compensation penetration to 92% (2009 average). Furthermore, is poised with proven solutions to help clients outreach to injured workers using nonparticipating navigate the pharmacy aspect of their overall pharmacies and recruiting pharmacies to join the medical costs, while ensuring a smooth process network also drive this metric.
for injured workers. Maintaining our focus on those areas which impact trend (generics, network Leveraging Consumerology®, our advanced penetration and Home Delivery), we are committed application of the behavioral sciences to to helping our clients drive out waste and lower healthcare, Express Scripts offers exciting new pharmacy costs.
approaches to increasing Home Delivery and Express Scripts 2009 Workers' Compensation Drug Trend Report Express Scripts 2009 W orkers' Compensation Drug T Express Scripts is committed to following, promoting and implementing sustainable practices. We apply global sustainability principles to the way we do business and the way we fulfill the needs of clients, patients and employees. Express Scripts is committed to proactively balancing economic development with environmental stewardship and social development, and operates its business in a manner that respects the environment and conserves natural resources. We uphold our commitment to environmental stewardship by printing this report using emission-free inks on recycled stocks containing 30% post-consumer waste that are certified by the Forest Stewardship Council (FSC). It was also printed using renewable energy provided by Pure Power from a Missouri-based wind farm.
Express Scripts, Inc.
One Express WaySt. Louis, Missouri 63121 2010 Express Scripts, Inc.
All Rights Reserved.


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