The Impact Of Tiered Co-pays: A Survey Of Patients And Pharmacists

The Impact of Tiered Co-Pays A Survey of Patients and Pharmacists Research Report Conducted by Harris Interactive September, 2003

This study was completed on behalf of and with support from the National Association of Chain Drug Stores Foundation, the National Pharmaceutical Council, and Pfizer Inc.

www.harrisinteractive.com ©2003, Harris Interactive Inc. All rights reserved.

Contents ¾ Background and Objectives

4

¾ Methodology

6

¾ Executive Summary

10

¾ Detailed Findings

23

¾Patients and Their Health Care Coverage

Page 2

¾All Patients with Drug Coverage

24

¾Patients with Employer-Sponsored Health Care Benefits

28

¾Patient Health Issues: Patients with Employer-Sponsored Health Care Benefits

33

¾Compliant and Non-Compliant Money Saving Strategies: Patients with Employer-Sponsored Health Care Benefits

40

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Contents (Cont.)

Page 3

¾Drug Selection Based on Patient Out-of-Pocket Costs: Patients with Employer-Sponsored Health Care Benefits

53

¾Overview: Pharmacists

60

¾Managed Care and the Pharmacist’s Practice: Pharmacists

68

¾Non-Compliance & Drug Selection Based on Patient Out-ofPocket Costs: Pharmacists

75

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Background and Objectives „

Employers increasingly have adopted strategies to reduce prescription drug expenditures, including cost-sharing arrangements that require employees to pay a greater share of the costs. A highly prevalent strategy is the multi-tier co-pay (MTC) benefit design, with three or more tiers, in which an employee’s out-of-pocket cost, or co-pay, for a prescription drug depends on that medicine’s tier level.

In 2002, approximately 57% of people with employer-sponsored health benefits were enrolled in MTC plans – growing from 29% of employees with this benefit design in 2000.1

The growing use of tiered benefit plans and increasing co-pay levels has prompted concern that higher co-pays may lead patients, particularly those with chronic illnesses, to reduce prescription drug compliance and, consequently, experience negative health outcomes that result in increased utilization of other health care services. 1Source:

Page 4

Kaiser Family Foundation and Health Research and Educational Trust “2002 Employer Health Benefits Survey”

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Background and Objectives (cont.) „ In August 2002, The National Association of Chain Drug Stores Foundation, The National Pharmaceutical Council, and Pfizer, Inc. commissioned Harris Interactive to assess and document the impact of tiered prescription drug formularies on the behavior and health outcomes of chronically ill patients.

„ Specifically, this research examines the relationship between multi-tier co-pay benefit plans and: ™ Prescription drug compliance and persistency; ™ Patient health outcomes; and ™ Pharmacy practice. Page 5

Harris Interactive Inc.

Methodology: Patient Survey Harris Interactive conducted 20-minute telephone interviews with 2,711 U.S. adults age 18+ with at least one chronic or recurring health condition and health coverage that includes a drug benefit ( representing 52% of all U.S. adults*).

g

1,499 interviews were conducted with respondents sampled via random digit dialing (RDD).

¾

An additional 1,212 interviews were conducted with respondents, recruited online via the Harris Interactive Chronic Illness panel, with any of four key chronic conditions: asthma, depression, type 2 diabetes, or high cholesterol. These additional interviews ensured sufficient numbers to permit group-level analyses for each of these conditions. Total interviews for each condition:

¾

♦ Asthma – 435

♦ Depression – 404

♦ Type 2 diabetes – 589

♦ High Cholesterol – 470

ƒ

The full sample includes patients covered by a range of health care plans, including private insurance, employer-sponsored coverage, Medicare, Medicaid, and coverage through the Veteran’s Administration (VA). The prescription drug benefits associated with each of these plans vary greatly. Therefore, to ensure a homogeneous sample, the bulk of the analysis focuses on the most predominant group – patients with employer-sponsored coverage. Except where indicated, patients with Medicare, Medicaid, and VA coverage are excluded from the analysis. * Source: Strategic Health Perspectives. Harris Interactive, 2002. Page 6

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Methodology: Patient Survey g

Interviews were conducted between December 3, 2002 and January 5, 2003.

ƒ

The patient data were weighted, where needed, to be projectable to all adults age 18+ diagnosed with a chronic condition and with prescription drug coverage. To ensure that the results were not biased by the over-representation of people with the four conditions described above, the data were also weighted so that these conditions are represented in correct proportion to their actual incidence among the general population.

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Harris Interactive Inc.

Methodology: Pharmacist Survey 1001 licensed retail pharmacists completed 20-minute self-administered Internet interviews. Pharmacists were sampled from a comprehensive national listing and invited to Harris Interactive’s website by US mail.

g

g

Interviews were conducted from December 2 through December 13, 2002.

The data were weighted to ensure that pharmacists are represented in correct proportion with respect to retail practice setting (chain vs. independent pharmacy) and geographic region. g

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Methodology: Significance Testing „

„

Significance is tested at the 95% confidence level Throughout the report, significance testing is reported using superscripts. Numbers with superscripts are significantly higher/lower than the number in the row or column titled with that superscript.

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Executive Summary

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Executive Summary Chronically ill individuals with employer-sponsored coverage are likely to be enrolled in drug benefit plans that require them to pay a co-pay. „

„

Seven in ten insured adults who suffer from chronic conditions are covered through employer-sponsored plans. Three in four of those with employer-sponsored coverage have drug benefits involving a co-pay. – At least half of individuals with employer-sponsored co-pay benefit plans have tiered co-pays, which require patients to pay more out-of-pocket for some medications than others. – 28% of individuals with employer-sponsored co-pay benefit plans are enrolled in plans with 2 tiers; 23% are enrolled in plans with 3 or more tiers.

„

Demographically, chronically ill people in employer-sponsored drug benefit plans with 3 or more tiers (multi-tier co-pays or “MTC”) are more likely than adults in general to be female, college-educated, white, and have lower household incomes.

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Executive Summary Chronically ill people in multi-tier co-pay drug benefit plans are more likely to report having difficulty paying out-of-pocket costs for medicines. „

People with MTC plans are much more likely than those in non-tiered, and two-tier plans to report having difficulty paying for their prescription medications. – This is not surprising given that they pay about 60% more per month than people in non-tiered plans for their prescription drugs.

People with multi-tier co-pay plans are less healthy than their nontiered, and in some cases two-tiered, counterparts. „

„

Compared to people with non-tiered employer-sponsored drug plans, those in MTC plans take more medicines. They are also more likely to have visited a hospital emergency room in the past year and make visits to the doctor beyond regular check-ups. They are also more likely to report missing days from work, contacting their health plans, and contacting their health benefits manager at work. Page 12

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Executive Summary Patients use a variety of strategies to reduce their out-of-pocket costs for prescription drugs. The likelihood of using these strategies is greater among patients with tiered co-pay benefit plans. „

„

Eight in ten with MTC plans report requesting a generic, requesting samples, or splitting pills in half with their doctor’s permission within the past year, compared to about five in ten individuals with non-tiered copay plans. Patients with tiered co-pay plans more frequently engage in “noncompliant” behaviors to reduce out-of-pocket costs, including delaying or deciding not to get a prescription filled, or taking smaller doses than prescribed, including splitting pills without the doctor’s permission. – Half of those with MTC plans report using these non-compliant strategies. They are twice as likely as those in non-tiered plans to use non-compliant strategies (54% vs. 25%).

Page 13

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Executive Summary Asthma and Depression patients in multi-tier co-pay benefit plans are especially likely to use non-compliant strategies in order to save money. „

Nine in ten asthma sufferers who have MTC employersponsored drug benefit plans report using money saving strategies. – Three in four MTC asthma sufferers report using non-compliant strategies within the past year, compared with half that number among asthma sufferers in non-tiered plans (75% vs. 34%).

„

Similarly, over nine in ten depression sufferers in MTC employersponsored plans use money-saving strategies. – Three in four (76%) depression sufferers in MTC plans report having been non-compliant within the past year in order to save money, compared with four in ten (42%) depression sufferers in non-tiered plans. Page 14

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Executive Summary Other key groups who are especially vulnerable to the effects of tiering include the less healthy and the less wealthy. „

„

„

Patients with 3+ tier employer-based drug benefit plans who are in poor health are twice as likely as their non-tiered counterparts to report having been non-compliant within the past year (53% and 66% among those in two- and three-tier plans). In contrast, only about a quarter of those with non-tiered employer plans reported non-compliance, regardless of their health status. Those with annual household incomes under $50,000 are similarly susceptible to the effects of tiering, with 50% and 69% of those with two- and three-tier plans reporting non-compliance, compared to only 29% among those with non-tiered plans. Page 15

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Executive Summary Non-compliance is not without risk. More than a third report having experienced health problems as a result of engaging in noncompliant behaviors to save on their prescription out-of-pocket drug costs. Again, people with tiered drug plans are disproportionately affected. „

„

On average, over a third (37%) of those who engaged in a noncompliant behavior, experienced health problems as a result of doing so. This translates to roughly 14% of all chronically ill adults with drug coverage, or 15.6 million people.* Fully half (51%) of those in three tier plans who engaged in a noncompliant behavior report resultant negative health outcomes, compared with only 26% on average, among those with non-tiered plans.

* Based on July 2002 U.S. Census Bureau population estimate of U.S. adults: 215,474,215. Page 16

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Executive Summary It is relatively common for patients to receive a drug with a lower co-pay specifically for the purpose of reducing patients’ out of pocket costs „

One-third (33%) of chronically ill patients with employer-sponsored drug coverage report either switching from a drug they were already taking or receiving a drug with a lower co-pay at the outset (at their own request or by choice of the doctor) for the purpose of saving money.

Individuals with MTC drug plans, and those who suffer from depression are most likely to report experiencing this cost-based prescribing. „

„

Over four in ten people with depression (43%) report having experienced some form of cost-based prescribing. Over half (54%) of those in MTC plans report having having these experiences, compared with only 17% of those in non-tiered plans and 33% of those in 2-tier plans.

Page 17

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Executive Summary

Individuals who have switched medications or received medicines with lower co-pays to save money are more likely than average to report having had problems with their prescription medications, as are individuals with multi-tier drug plans. „

„

Those who have received or switched to a drug with a lower co-pay within the past year are about twice as likely as those who have not, to report having taken a drug that was ineffective (25% vs. 12%). They are also twice as likely to report taking a drug that caused side effects (27% vs. 14%). Almost three in ten individuals (27%) with MTC plans report having taken a medication in the past year that was ineffective, and about the same number (29%) experienced side effects from a medication.

Page 18

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Executive Summary Pharmacists confirm the experiences reported by patients, reporting that patient non-compliance is a common occurrence.

„

„

Two-thirds (65%) report that patients delay getting prescriptions filled very or somewhat often in order to reduce their out-of-pocket costs for prescription drugs. A majority also report that patients somewhat or very often decide not to get prescriptions filled (57%) and take their medications less frequently than prescribed (56%) in order to save money.

Page 19

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Executive Summary By an overwhelming majority, pharmacists suspect that patients take less than optimal drugs due to insurance restrictions. They also believe that the substituted drugs may be ineffective or cause side effects. „

„

„

Nine in ten (90%) pharmacists suspect that their patients with drug coverage end up taking less-than-optimal medications because of insurance restrictions. Half (51%) believe that it is somewhat or very common that the substituted drug is not effective. Four in ten (39%) believe it is somewhat or very common that the substituted drug causes side effects. About two-thirds (64%) believe that it is somewhat or very common that patients end up making additional visits to a doctor as a result of drug substitution.

Page 20

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Executive Summary Pharmacists have a lot of experience dealing with drug plans and they know them well. „

„

„

The surveyed pharmacists have been in practice an average of 17 years and these pharmacists fill more than 750 prescriptions per average week. On average, 80% of these are covered by some type of drug plan – half (52%) by plans that involve a co-pay. Nearly nine in ten (87%) pharmacists say that they are somewhat or very knowledgeable about options under multi-tier drug plans. In contrast, 92% believe that patients are either not at all or not very knowledgeable about options under these plans. Prescriptions most commonly filled include antidepressants, analgesics, diabetes therapy, vascular agents, and oral anti-infectives.

Since becoming widespread, multi-tiered drug plans have caused more pharmacists to spend time dealing with patients about their drug benefits than about their treatments. „

„

Eight in ten pharmacists say that, since multi-tier drug plans have become widespread, they spend somewhat or much more time dealing with health plans (82%) and educating patients about their drug benefits (83%). Only a little more than a quarter (27%) spend more time communicating with and educating their patients about their medications.

Page 21

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Executive Summary Ideally, pharmacists would spend more of their time communicating with patients and less time dealing with health plans. „

„

„

Pharmacists spend most of their time filling prescriptions – ranking this activity higher than any other in terms of actual time spent. However pharmacists would prefer to spend most of their time communicating with and educating patients on their treatments – ranking this activity #1 in terms of time ideally spent. Pharmacists ranked communicating with health plans last among their list of ideal activities.

Working with these plans has become more difficult in the last five years, and has made pharmacists’ jobs more difficult. „

„

Among those in practice at least five years, 85% say that working with the typical health plan today is somewhat or much more difficult than working with the typical health plan five years ago. 87% also say that their jobs are more difficult today overall than they were five years ago; among this group, nine in ten say that the move toward drug formularies (92%) and multi-tier drug plans (92%) are the cause of the difficulty.

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Detailed Findings

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Patients and Their Health Care Coverage

All Patients With Drug Coverage

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Types of Patient Health Care Coverage All Patients With Drug Coverage • Most patients with health insurance and prescription drug coverage are covered through an employment-based health care plan. Health insurance or an HMO through your or someone else's work or union

71%

Health insurance or an HMO bought directly by you or another member of your family

35%

Medicare or a Medicare HMO

28%

15%

Medicaid, Medicaid HMO, or medical assistance

Health coverage through the Veteran's Administration

7%

Health insurance from some other source

19%

Note: percentages exceed 100% because some patients have health coverage through more than one source. Q320: People have different kinds of health plans or health insurance, including those provided by the government. Are you covered by (READ EACH ITEM), or not? Base: All Respondents (n=2711) Page 25

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Demographic Profile by Health Care Coverage All Patients With Drug Coverage US Adults Age 18+ %

Employer-Sponsored Coverage* (n=1501) %

Medicare (n=456) %

Medicaid (n=349) %

VA Coverage (n=158) %

Gender Male Female

48 52

45 55

40 60

43 57

78 22

Age (mean years)

43

43

64

49

55

College degree

16

32

28

18

41

Married

58

68

68

42

66

Income Less than $50,000 $50,000 or more

53 39

40 47

57 25

69 12

48 35

Race White Minority

74 26

79 19

84 8

63 32

68 25

* Throughout this report, the employer-sponsored coverage group excludes those who also have coverage through Medicare, Medicaid or the Veteran’s Administration. Page 26

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Type of Drug Benefit by Health Care Coverage All Patients With Drug Coverage

Employer-Sponsored Coverage (n=1501) (a) %

Medicare (n=456) (b) %

Medicaid (n=349) (c) %

VA Coverage (n=158) (d) %

Co-Pay

75

65c

46

59c

Co-Insurance

13

19d

14

12

Combination

8

6

8

6

Not sure

3

9

28bd

17b

Non-Tiered

35

36

55b

48b

2 Tiers

28

27

24

29

3+ tiers

25

18cd

5

7

Not sure

11

17c

5

12c

Total

Co-pay Plans

Q600, 605, 610, 615, 620, 625 (see questionnaire – Appendix B) Base: All Respondents Page 27

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Patients and Their Health Care Coverage All Patients With Drug Coverage

Patients With Employer-Sponsored Health Care Benefits

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Drug Coverage Patients With Employer-Sponsored Health Care

All Plans CoInsurance 13% Combination* 8%

Co-Pay Plans Not Sure 11%

NonTiered 35%

Not Sure 3% 3+ Tiers 25%

Co-Pay 75% 2 Tiers 28% Q600, 605, 610, 615, 620, 625 Base: All Respondents (n=1501) * Note: Combination plans are those in which patients pay a co-pay for some drugs and a percentage (co-insurance) for other drugs. Combination plans are presented alongside co-insurance plans in this analysis for purposes of convenience. Page 29

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Demographic Profile by Co-pay Coverage Patients With Employer-Sponsored Health Care All US Adults Age 18+ %

Total w/ Employer Coverage (n=1501) a %

Non-tiered (n=365) b %

2 Tiers (n=335) c %

3+ Tiers (n=274) d %

Gender Male Female

48 52

45 55b

53ac 47

45 55b

37a 63abc

Age (mean years)

43

43

43

44

42

College degree

16

32b

23

34b

38ab

Married

58

68

65

71

71

53

40

40

37

51abc

39

47

45

51

44

74 26

79b 19c

73 25acd

84b 14

81b 15

Income Less than $50,000 $50,000 or more Race White Minority

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Patient Chronic Conditions by Co-Pay Coverage Patients With Employer-Sponsored Health Care „

Patients in tiered co-pay plans are more likely than adults in general and those in non-tiered plans to suffer from depression. Percent With Diagnosed Medical Condition Total (n=1501) (a)

Non-tiered (n=365) (b)

2 Tiers (n=335) (c)

3+ Tiers (n=274) (d)

Diabetes

11

9

13

13

High Cholesterol

30

29

34

33

Allergies

20

19

18

24

Asthma

19

17

19

21

Hypertension

16

17

20

19

Depression

18

15

22b

24

Arthritis

7

7

8

8

Q400. (Do you have any recurring or chronic health condition diagnosed by a health professional that has lasted or is expected to last for at least a year?) What condition is that? Please name all recurring or chronic medical conditions that you have. Base: All Respondents Page 31

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Overall Health by Co-pay Coverage Patients With Employer-Sponsored Health Care „

Patients in MTC co-pay plans are more likely than others to report being in fair or poor health

Excellent/Very Good Health

Fair/Poor Health

47% 41%

39% b

36% 30%

33%a,b,c

38%

27%

27%

11%

9%

9%

12%

Total (a)

Non-tiered (b)

2 Tiers (c)

3+ Tiers (d)

Excellent

Very Good

22% 5%

17% 4%

17% Total (a)

13% Non-tiered (b)

Fair

Poor

Q330. Would you say your health, in general, is excellent, very good, good, fair or poor? Base: All Respondents (total n=1501; non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 32

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23% 3% 20%

2 Tiers (c)

7%

26%

3+ Tiers (d)

Patient Health Issues

Patients With Employer-Sponsored Health Care Benefits

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Patient Health Issues – Past 12 Months Patients With Employer-Sponsored Health Care In the past 12 months, two-thirds of patients have contacted a doctor for a reason other than a regular check-up, and almost half have contacted their health plan or insurance company.

„

Percent who Experienced Health Issue

Mean # of times experienced

Make any visits to a doctor in addition to regular check-ups

66%

Contact your health plan or insurance com pany

Adm itted to a hospital

6.1

Contact your health plan or insurance com pany

48%

Miss any days from w ork

Visit a hospital ER

Make any visits to a doctor in addition to regular check-ups

42%

3.7

Miss any days from w ork

22%

17%

12.4

Visit a hospital ER

1.6

Adm itted to a hospital

1.6

Visit an urgent care facility

18%

Visit an urgent care facility

2.2

Contact health benefits m anager at w ork

18%

Contact health benefits m anager at w ork

2.3

Q500. Base: Q510. Base:

In the past 12 months, for any reason did/were you [INSERT ITEM], or not? All Respondents (n=1501) And how many times did that happen in the past 12 months? Have Done Action in Past 12 Months (n=1073)

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Past Year Health Issues Patients With Employer-Sponsored Health Care „

Patients with MTC plans are more likely than those with non-tiered plans to have visited an emergency room or been admitted to a hospital in the past year. 27%

% Who Experienced Each Health Issue 23%

22% 19%

19%

19%

18%

16%

16%

Visit an urgent care facility

Admitted to a hospital

Non-Tiered (a)

2 Tiers (b)

3+ Tiers (c)

Q500. In the past 12 months, for any reason did/were you [INSERT ITEM], or not? Base: All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 35

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Visit a hospital ER

a

Past Year Health Issues Patients With Employer-Sponsored Health Care (cont.) „

Patients with MTC plans are more likely to have contacted their health benefits manager or insurance company, missed days from work, or made a special visit to the doctor. 73% a

% Who Experienced Each Health Issue

67% a 61% a,b 54%

49% b 40% 38%

43% 45%

25% a 16%

19%

Contact health benefits manager at work

Miss any days from work Contact your health plan or insurance company Non-Tiered (a)

2 Tiers (b)

Q500. In the past 12 months, for any reason did/were you [INSERT ITEM], or not? Base: All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 36

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3+ Tiers (c)

Make any visits to a doctor in addition to regular check-ups

Past Year Prescription Medication Patients With Employer-Sponsored Health Care „ „

Nearly all patients have taken prescription medication in the past year. Patients with MTC plans are more likely than those with non-tiered plans to have taken a prescription medication in the past year. Took Rx Medication

84%

82%

Total (a)

Non-Tiered (b)

90% b

92% b

2 Tiers (c)

3+ Tiers (d)

Q405. In the past 12 months, have you taken any prescription medications to treat a chronic or recurring health or medical condition? Base: All Respondents (total n=1501; non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 37

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Number of Rx Medications Patients With Employer-Sponsored Health Care „

Patients with MTC plans take more prescription medications than those in non-tiered plans. Mean # of Medications

3.1 b,c 2.4 b

2.3 1.8

1.9 b

1.7

2.1

b

1.4

Past 12 Months Total (a)

Total Current Medications Non-Tiered (b)

2 Tiers (c)

3+ Tiers (d)

Q415: How many different prescription medications, in total, have you taken in the past 12 months for (CONDITION)? Q420: And how many different prescription medications, in total, do you CURRENTLY take for (CONDITION)? Base: All Respondents (total n=1501; non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 38

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Difficulty Paying Out-of-Pocket Costs Patients With Employer-Sponsored Health Care „

People with MTC plans are much more likely than others to report having difficulty paying for their prescription medications –perhaps not surprising, given that they pay about $50 per month more than people in two-tier plans and $40 per month more than people in non-tiered plans for their prescription drugs.

Average monthly out-ofpocket cost

$70.00

$60.30

$47.40

$97.60 c

46% b,c

30% b,c,d 24% 19%

% Responding Extremely/Somewhat Difficult To Pay Out-of-Pocket Costs

Total (a)

Non-Tiered (b)

2 Tiers (c )

3+ Tiers (d)

Q680 Not counting the amount covered by your health plan, about how much do you spend per month out-of-pocket for your prescription medicines? Base: All Respondents (total n=1501; non-tiered n=365; 2 tiers n=335; 3+ tiers n=274). Q690 How difficult is it for you to pay the out-of-pocket costs for your prescription medications ― extremely difficult, somewhat difficult, not too difficult, or not at all difficult? Base: Out-of-Pocket Costs are Greater Than Zero (total n=1336; non-tiered n=312; 2 tiers n=313; 3+ tiers n=263). Page 39

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Compliant and Non-Compliant Money Saving Strategies

Patients With Employer-Sponsored Health Care Benefits

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Defining Compliance In this study, we refer to two distinct sets of behaviors patients use to save on their out-of-pocket costs for prescription medicines. „

Compliant strategies include: – Requesting a generic drug, – Asking physician for samples, and – Splitting pills in half with doctor’s permission.

„

Non-compliant strategies include: – Deciding not to get a prescription filled, – Delaying getting a prescription filled, – Taking smaller doses of a medication than prescribed or splitting pills in half without a doctor’s permission, and – Taking a medication less frequently than prescribed. Page 41

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Strategies to Reduce Out-Of-Pocket Costs for Prescription Medicines Patients With Employer-Sponsored Health Care „

Two-thirds of all patients engaged in some strategy to save money.

• Used any strategy to save money

67%

* Used any compliant strategy

60% 48%

Requested a generic drug instead of a name brand Asked physician for samples Split pills in half with doctor's permision

37% 11%

* Used any non-compliant strategy

37% 27%

Delayed getting a Rx filled Decided not to get a Rx filled

23%

Taken medication less frequently than prescribed Taken smaller doses of a medication or split pills in half without doctor's permission

19% 10%

Q700. In the past 12 months, have you done any of the following in order to reduce your out-of-pocket costs for prescription medications? Please answer “yes” only if the main reason you did this was to save money. Have you…? Base: All Respondents (total n=1501) Page 42

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Strategies to Reduce Out-of-Pocket Costs by Co-pay Coverage Patients With Employer-Sponsored Health Care „

Patients in MTC plans are more likely than others to use these strategies. 52%

Used any strategy to save money

a

67%

a,b

86% 45%

Used any compliant strategy

a

63%

a,b

78% 29%

Requested a generic drug instead of a name brand

a

48%

26%

Asked physician for samples

Split pills in half with doctor's permision

a,b

68%

a

37%

a,b

49% 8% 10% a,b

17%

Non-Tiered (a)

2 tiers (b)

3+ Tiers (c)

Q700. In the past 12 months, have you done any of the following in order to reduce your out-of-pocket costs for prescription medications? Please answer “yes” only if the main reason you did this was to save money. Have you…? Base: All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274 ) Page 43

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Strategies to Reduce Out-of-Pocket Costs by Co-pay Coverage Patients With Employer-Sponsored Health Care „

Patients in MTC plans are more likely than others to use non-compliant strategies. 25%

Used any non-compliant strategy

33% 54% 18% 22%

Delayed getting a Rx filled

43% 11% Decided not to get a Rx filled

18%

12% 16% 31%

Taken smaller doses of a medication or split pills in half without doctor's permission

5% 8%

Non-Tiered (a)

2 tiers (b)

14%

a,b

a

38% Taken medication less frequently than prescribed

a,b

a,b

a,b

a

3+ Tiers (c)

Q700. In the past 12 months, have you done any of the following in order to reduce your out-of-pocket costs for prescription medications? Please answer “yes” only if the main reason you did this was to save money. Have you…? Base: All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 44

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Health Problems Resulting From Non-Compliance by Co-pay Coverage Patients With Employer-Sponsored Health Care • Patients in MTC plans are twice as likely to experience health problems as a result of non-compliance as those in non-tiered plans.

Experienced health problems as a result of non-complaint behavior 51% 39% 26%

Non-Tiered (a)

2 tiers (b)

3+ Tiers (c)

Q710. In the past 12 months, do you believe you experienced any health problems as a result of [INSERT ITEM] in order to save money? Base: Have Done Non-compliant Behavior (non-tiered n=76; 2 tiers n=106; 3+ tiers; n=143) Page 45

Harris Interactive Inc.

Patient Strategies to Reduce Out-of-Pocket Costs: by Condition and Co-Pay Coverage Patients With Employer-Sponsored Health Care

Asthma

Depression

Total n=267 (A)

Non-tiered n=54 (B)

2 Tiers n=70 (C)

3+ Tiers n=56 (D)

Total n=231 (A)

Non-tiered n=41 (B)

2 Tiers n=65 (C)

3+ Tiers n=57 (D)

Used any strategy to save money

67

49

68b

91bc

79

56

82b

94bc

Used any compliant strategy

61

33

65b

88bc

71

40

80b

85b

-Requested a generic drug

49

23

49b

74bc

52

22

55b

69b

-Asked physician for samples

41

16

43b

62bc

56

35

57b

67b

-Split pills in half with doctor’s permission

15

10

8

37bc

18

12

16

28b

49

34

38

75bc

58

42

58

76bc

-Delayed getting a Rx filled

35

22

31

64bc

48

28

46

69bc

-Decided not to get a Rx filled

33

19

15

60bc

34

22

32

58bc

-Taken Rx less frequently than prescribed

24

20

13

48bc

32

20

20

51bc

-Taken smaller doses of medication or split pills without doctor’s permission

11

9

4

17c

21

14

20

28

Used any non-compliant strategy

Page 46

Harris Interactive Inc.

Patient Strategies to Reduce Out-of-Pocket Costs: by Condition and Co-Pay Coverage (cont.) Patients With Employer-Sponsored Health Care Type 2 Diabetes

High Cholesterol

Total n=325 (A)

Non-tiered n=60 (B)

2 Tiers n=91 (C)

3+ Tiers n=76 (D)

Total n=259 (A)

Non-tiered n=66 (B)

2 Tiers n=66 (C)

3+ Tiers n=54 (D)

68

53

62

83bc

67

57

61

82bc

61

31

60b

81bc

61

46

59

73b

-Requested a generic drug

50

24

50b

71bc

51

34

48

65b

-Asked physician for samples

38

18

41b

48b

34

22

31

42b

-Split pills in half with doctor’s permission

11

6

11

18b

9

5

10

9

Used any non-compliant strategy

32

27

27

36

30

23

19

40bc

-Delayed getting a Rx filled

22

3

20b

35bc

21

11

11

29bc

-Decided not to get a Rx filled

19

18

12

29c

19

8

11

27bc

-Taken Rx less frequently than prescribed

19

25

14

23

19

14

10

26c

-Taken smaller doses of medication or split pills without doctor’s permission

10

1

9b

19b

8

1

3

5

Used any strategy to save money Used any compliant strategy

Page 47

Harris Interactive Inc.

Patient Strategies to Reduce Out-of-Pocket Costs: by Income and Co-Pay Coverage Patients With Employer-Sponsored Health Care Less Than $50,000 per Year

$50,000 per Year or More

Total

Non-tiered

2 Tiers

3+ Tiers

Total

Non-tiered

2 Tiers

3+ Tiers

n=584 (A)

n=142 (B)

n=120 (C)

n=119 (D)

n=787 (A)

n=177 (B)

n=187 (C)

n=139 (D)

Used any strategy to save money

76

57

76b

92bc

60

45

63b

79bc

Used any compliant strategy

67

45

69b

85bc

55

41

60b

71bc

57

38

60b

72bc

41

22

40b

65bc

-Asked physician for samples

41

21

36b

57bc

34

28

38b

43b

-Split pills in half with doctor’s permission

16

13c

6

26bc

8

5

12b

8

50

29

50b

69bc

27

17

25

39bc

-Delayed getting a Rx filled

38

17

33b

58bc

19

12

17

27bc

-Decided not to get a Rx filled

31

13

34b

48bc

16

6

10

28bc

-Taken Rx less frequently than prescribed

27

17

25

38bc

15

9

12

23bc

-Taken smaller doses of medication or split pills without doctor’s permission

15

8

16b

20b

5

1

4

6b

-Requested a generic drug

Used any non-compliant strategy

Page 48

Harris Interactive Inc.

Patient Strategies to Reduce Out-of-Pocket Costs: by Health Status and Co-Pay Coverage Patients With Employer-Sponsored Health Care

Excellent/Very Good Health

Fair/Poor Health

Total

NonTiered

2 Tiers

3+ Tiers

Total

Nontiered

2 Tiers

3+ Tiers

n=594 (A)

n=173 (B)

n=116 (C)

n=87 (D)

n=332 (A)

n=58 (B)

n=81 (C)

n=82 (D)

Used any strategy to save money

61

48

63b

82bc

76

54

78b

90bc

Used any compliant strategy

56

42

61b

73b

69

45

74b

85b

-Requested a generic drug

45

26

47b

64bc

59

35

58b

81bc

-Asked physician for samples

31

25

31

43b

49

32

46

59b

8

6

8

14

15

10

8

26bc

Used any non-compliant strategy

29

23

22

44bc

51

27

53b

66b

-Delayed getting a Rx filled

20

17

14

31bc

43

21

43b

59bc

-Decided not to get a Rx filled

19

12

12

32bc

31

12

29b

50bc

-Taken Rx less frequently than prescribed

13

10

11

13

32

16

34b

47b

-Taken smaller doses of medication or split pills without doctor’s permission

5

4

4

5

20

14

21

27

-Split pills in half with doctor’s permission

Page 49

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Patient Strategies to Reduce Out-of-Pocket Costs: by Gender and Co-Pay Coverage Patients With Employer-Sponsored Health Care Male

Female

Total

Nontiered

2 Tiers

3+ Tiers

Total

Nontiered

2 Tiers

3+ Tiers

n=530 (A)

n=157 (B)

n=124 (C)

n=77 (D)

n=971 (A)

n=208 (B)

n=211 (C)

n=197 (D)

Used any strategy to save money

61

47

67b

80bc

71

59

67

90bc

Used any compliant strategy

55

40

61b

75bc

65

50

64

80bc

-Requested a generic drug

42

22

43b

69bc

53

37

52b

68bc

-Asked physician for samples

31

24

33

37b

42

28

39b

56bc

-Split pills in half with doctor’s permission

9

6

10

14

13

11

9

19bc

Used any non-compliant strategy

28

19

30b

34b

45

32

35

66bc

-Delayed getting a Rx filled

20

15

18

25

34

22

26

54bc

-Decided not to get a Rx filled

18

8

18b

26b

27

14

19

45bc

-Taken Rx less frequently than prescribed

13

6

13b

22b

25

19

19

36bc

-Taken smaller doses of medication or split pills without doctor’s permission

7

2

4

10b

12

8

11

17b

Page 50

Harris Interactive Inc.

Patient Strategies to Reduce Out-of-Pocket Costs: by Age and Co-Pay Coverage Patients With Employer-Sponsored Health Care Under Age 50 Total

Nontiered

Nontiered

2 Tiers

3+ Tiers

n=806 (A)

n=184 (B)

n=161 (C)

n=162 (D)

n=657 n=172 (A) (B)

n=168 (C)

n=105 (D)

Used any strategy to save money

69

54

76b

89bc

62

51

57

79bc

Used any compliant strategy

63

47

70b

80bc

57

43

54b

75bc

-Requested a generic drug

50

29

51b

69bc

46

32

45b

70bc

-Asked physician for samples

41

30

43b

52b

31

21

29

43bc

-Split pills in half with doctor’s permission

11

8

9

17bc

13

9

11

20bc

42

29

38

60bc

27

19

26

37b

-Delayed getting a Rx filled

32

22

26

49bc

18

10

18b

26b

-Decided not to get a Rx filled

26

12

22b

44bc

14

8

15b

21b

-Taken Rx less frequently than prescribed

22

13

20

34bc

14

11

12

20b

-Taken smaller doses of medication or split pills without doctor’s permission

11

7

9

16b

7

2

8b

7

Used any non-compliant strategy

Page 51

2 Tiers

Age 50+

Harris Interactive Inc.

3+ Tiers

Total

Patient Strategies to Reduce Out-of-Pocket Costs: by Education and Co-Pay Coverage Patients With Employer-Sponsored Health Care College Graduate

Non-College Graduate

Total

Nontiered

2 Tiers

3+ Tiers

Total

Nontiered

2 Tiers

3+ Tiers

n=732 (A)

n=151 (B)

n=166 (C)

n=145 (D)

n=747 (A)

n=208 (B)

n=166 (C)

n=125 (D)

64

49

63b

76bc

69

54

71b

93bc

58

45

60b

67b

62

46

66b

86bc

-Requested a generic drug

47

30

46b

59bc

49

29

50b

75bc

-Asked physician for samples

36

27

29

42bc

38

26

43b

55bc

-Split pills in half with doctor’s permission

9

6

9

9

13

10

11

23bc

Used any non-compliant strategy

32

19

22

42bc

41

28

41b

62bc

-Delayed getting a Rx filled

22

12

14

28bc

31

20

29b

54bc

-Decided not to get a Rx filled

18

6

13b

29bc

26

12

23b

44bc

-Taken Rx less frequently than prescribed

16

8

9

22bc

22

14

22b

37bc

-Taken smaller doses of medication or split pills without doctor’s permission

9

2

6

12b

10

6

10

15b

Used any strategy to save money Used any compliant strategy

Page 52

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Drug Selection Based on Patient Out-of-Pocket (OOP) Costs

Patients With Employer-Sponsored Health Care Benefits

www.harrisinteractive.com ©2003, Harris Interactive Inc. All rights reserved.

OOP Cost-Based Drug Selection: Three Scenarios Patients With Employer-Sponsored Health Care • One in three experienced some form of cost-based drug selection within the past year.

Experienced any cost-based drug selection

33%

- Patient asked doctor or pharmacist to give them less costly drug

23%

- Doctor chose one drug over another to save patient money - Patient switched from drug already taking to less expensive drug to save money

19%

13%

Q800 In the past 12 months, has your doctor chosen a particular drug for you instead of another drug he or she might prescribe in order to save you money? Q805 In the past 12 months, have you asked your doctor or pharmacist to give you a drug that would cost you less money than another drug you might be prescribed? Q810 In the past 12 months, have you had to switch from a drug you had already been taking to a less expensive drug in order to save money? Base: All Respondents (total n=1501) Page 54

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OOP Cost-Based Drug Selection by Health Condition Patients With Employer-Sponsored Health Care • People with depression are especially likely to experience cost-based drug selection. High Cholesterol (n=259) % d

Asthma (n=267) % a

Depression (n=231) % b

Type 2 Diabetes (n=325) % c

34

43

34

34

-Patient asked doctor or pharmacist to give them less costly drug

23

28

23

26

-Doctor chose one drug over another to save patient money

19

28

24

21

-Patient switched from drug already taking to less expensive drug to save money

8

20a

14

16a

Experienced any cost-based drug selection

Q800 In the past 12 months, has your doctor chosen a particular drug for you instead of another drug he or she might prescribe in order to save you money? Q805 In the past 12 months, have you asked your doctor or pharmacist to give you a drug that would cost you less money than another drug you might be prescribed? Q810 In the past 12 months, have you had to switch from a drug you had already been taking to a less expensive drug in order to save money? Base: All Respondents Page 55

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OOP Cost-Based Drug Selection by Co-Pay Coverage Patients With Employer-Sponsored Health Care • People with MTC plans are twice as likely as those in non-tiered plans to experience cost-based drug selection. 17%

Experienced any cost-based drug selection

33% 54%a,b 12%

-Patient asked doctor or pharmacist to give them less costly drug

24% 41%a,b 9% 17%a

-Doctor chose one drug over another to save patient money

34%a,b 7%

-Patient switched from drug already taking to less expensive drug to save money

11% 21%a,b

Non-Tiered (a)

Q800 Q805 Q810 Base:

2 tiers (b)

3+ Tiers (c)

In the past 12 months, has your doctor chosen a particular drug for you instead of another drug he or she might prescribe in order to save you money? In the past 12 months, have you asked your doctor or pharmacist to give you a drug that would cost you less money than another drug you might be prescribed? In the past 12 months, have you had to switch from a drug you had already been taking to a less expensive drug in order to save money? All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274)

Page 56

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Problems With Medication in Past Year: by OOP Cost-Based Drug Selection Patients With Employer-Sponsored Health Care • Patients who experienced cost-based drug selection are twice as likely as those who haven’t to report experiencing problems with their medications in the past year.

25%

27% b

b

14% 12%

Not being effective in treating the condition for which it was prescribed Experienced Cost-Based Drug Selection (a)

Causing negative side-effects No Cost-Based Drug Selection (b)

Q520. Thinking about any medication you have taken for a chronic condition in the past 12 months, was there ever a problem with that medication? Base: Taken RX Medication for Chronic Illness (total n=2365; experienced drug substitution n=791; no substitution n=1503) Page 57

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Problems With Medication in Past Year: by Co-pay Coverage Patients With Employer-Sponsored Health Care • Patients in MTC plans are twice as likely as those in non-tiered plans to report experiencing problems with their medications in the past year.

Not being effective in treating the condition for which it was prescribed

12% 22%

a

27%

a

15% Causing negative side-effects

25%

a

29%

Non-Tiered (a)

2 Tiers (b)

a

3+ Tiers (c)

Q520. Thinking about any medication you have taken for a chronic condition in the past 12 months, was there ever a problem with that medication? Base: Taken RX Medication for Chronic Illness (non-tiered n=309; 2 tiers n=301; 3+ tiers n=256) Page 58

Harris Interactive Inc.

Topics Discussed With Pharmacist Patients With Employer-Sponsored Health Care • Patients in MTC plans are much more likely than others to discuss less expensive b medication alternatives and details of their drug plans. 55% a 53%

45%

44% 39% 36%

a,b 28% a,b 21% 18% 11% 9%

Alternative medications that may cost less

53%

45%

45%45%

41%

40%

a 25% 18% 15%

11%

Details of drug plan

Other treatments for condition

Dosage

Non-tiered (a)

Other medicines that might interact

2 Tiers (b)

How/when to take the Rx

Possible side effects

3+ Tiers (c)

Q900. Thinking of the times when you go to a pharmacy to get a new prescription filled or pick up the prescription, do you typically discuss with a pharmacist…? Base: All Respondents (non-tiered n=365; 2 tiers n=335; 3+ tiers n=274) Page 59

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Overview

Pharmacists

www.harrisinteractive.com ©2003, Harris Interactive Inc. All rights reserved.

Pharmacist Practice Demographics Total % Pharmacy Type Chain Independent

66 34 Total %

Region East South Midwest West

Chain

20 38 23 19

Independent

(%)

(%)

19 39 22 20

22 37 25 17

Years in Practice <5 5 – 15 16 –29 30 or more Average Years in Practice

14 34 34 17 17.6

16 37 32 15 16.5

11 29 38 22 19.6

Average Prescriptions Filled Per Week

767

809

685

Average Hours Worked Per Week

41.7

41.2

42.7

Q330. Q335. Q340. Base:

For how many years in total have you practiced as a pharmacist in retail settings? Approximately how many prescriptions do you personally fill per average week? In an average week, approximately how many hours do you work as a retail pharmacist? All Qualified Respondents (n=1001)

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Prescriptions Filled by Therapeutic Class Pharmacists % Who Listed Drug Class Among Top 5 Most Frequently Filled Prescriptions Psychotherapeutics – Antianxiety Psychotherapeutics – Antidepressants Psychotherapeutics – Antipsychotics Psychotherapeutics – Other

30 64 5 1

Vascular agents - ARBs, including ACEs Vascular agents - Alpha blockers, Beta blockers, Alpha-beta blockers Vascular agents – CCBs Vascular agents - Other

44 31 4 1

Oral systemic anti-infectives Analgesics Hormones Respiratory therapy

42 61 25 12

Top 5 most frequently filled prescriptions are indicated in red Q345. For which 5 classes of drugs do you most frequently fill prescriptions? Please choose up to 5 drug classes from the list below. Base: All Qualified Respondents (n=1001) Page 62

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Prescriptions Filled by Therapeutic Class (cont.) Pharmacists % Who Listed Drug Class Among Top 5 Most Frequently Filled Prescriptions Gastrointestinal Antiarthritics Antihyperlipidemics Diabetes therapy Diuretics

25 10 30 48 7

Neurologic - Anti-seizure medications Neurologic – Neuralgia Neurologic - Alzheimer’s disease/Dementia Neurologic – Other Thyroid therapy Antihistamines

8 6 1 2 18 17

Cardiac agents - Coronary vasodilators Cardiac agents - Positive inotropic agent Oral anti-fungal agents Genitourinary

5 1 * 1

Top 5 most frequently filled prescriptions are indicated in red Q345. For which 5 classes of drugs do you most frequently fill prescriptions? Please choose up to 5 drug classes from the list below Base: All Qualified Respondents (n=1001) Page 63

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Prescriptions Covered by Health Plan/Insurance Pharmacists • 80% of all prescriptions pharmacists fill are covered by some kind of health plan. Mean

% of Total

Total Prescriptions Filled Per Week

767

100

# Covered by Insurance or Health Plan

619

80

# Covered by plans with co-pay*

404

52

# Covered by plans with coinsurance*

79

11

# Covered by plans with combination of both*

67

9

Prescriptions (per week) denied coverage due to steptherapy restrictions

5.8

0.7

Q335. Approximately how many prescriptions do you personally fill per average week? Q410. In an average week, approximately how many of the … prescriptions you fill are paid, at least in part, by an insurance company or health plan? Q500/501. Approximately how many of the prescriptions you fill in an average week (that are covered by an insurance company or health plan) are covered by each of the following? Q505. About how many times in the past four weeks was coverage for a prescription you tried to fill denied because it was out of sequence in a mandated step-therapy requirement? (re-calculated as number per week) Base: All Qualified Respondents (n=1001) *Base: Fill prescriptions that are covered by Insurance/Health Plan Page 64

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Knowledge of Multi-Tier Drug Plans Pharmacists • Pharmacists are very confident in their own understanding of options available under multi-tier drug plans, but believe patients are far less knowledgeable.

64% 52% 40% 23% 10%

8%

2%

0% Very knowledgeable

Somewhat knowledgeable

Not very knowledgeable

Not at all knowledgeable

Pharmacists' Assessment of Patient Knowledge Pharmacists' Assessment of Own Knowledge Q510. In your opinion, how knowledgeable are patients about the options they have under the multi-tier drug plans? Q515. How knowledgeable are you, as a pharmacist, about the options patients have under their multi-tier drug plans? Base: All Qualified Respondents (n=1001)

Page 65

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Knowledge of Multi-Tier Drug Plans Independent vs. Chain Pharmacists • Chain and independent pharmacists give similar assessments of their knowledge of options available under multi-tier drug plans.

Patients’ Knowledge

Pharmacists’ Knowledge

53% 49%

66% 62% 42%

39%

21%

25%

9% 7%

11% 10% 2% 3%

0% 0% Very Somewhat Not very Not at all knowledgeable knowledgeable knowledgeable knowledgeable

Independent (a)

Very Somewhat Not very Not at all knowledgeable knowledgeable knowledgeable knowledgeable

Chain (b)

Q510. In your opinion, how knowledgeable are patients about the options they have under the multi-tier drug plans? Q515. How knowledgeable are you, as a pharmacist, about the options patients have under their multi-tier drug plans? Base: All Qualified Respondents (Independent: n=320; Chain: n=681)

Page 66

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Time Spent On Professional Activities – Actual vs. Ideal Pharmacists • Pharmacists would ideally spend more time educating patients and less time communicating with health plans

Mean Rank Order Actual Ideal

Activity Filling prescriptions including compounding, counting/measuring doses, labeling, controlled substance reporting, checking for interactions, etc.

1

2

Communicating with/educating patients on treatments, dosages, how to take medications, etc.

2

1

Communicating with health plans/insurers about patients’ drug benefits, including required paperwork

3

6

Performing administrative tasks including order entry, bookkeeping, managing staff, etc.

4

4*

Communicating with/educating patients on their drug benefits, etc.

5

3

Communicating with physicians about patients’ drug benefits

6

4*

Q400/401. Please rank each of the following activities in terms of the amount of time you spend performing them in a typical week, where 1 = “spend most time performing” and 6 = “spend least time of amount on.” Q405/406. Now rank each of the following activities in terms of how much time you would ideally like to spend on them, where 1 = “spend most time performing” and 6 = “spend least time of amount on.” * Indicates a tie Base: All Qualified Respondents (n=1001) Page 67

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Managed Care and The Pharmacist’s Practice

Pharmacists

www.harrisinteractive.com ©2003, Harris Interactive Inc. All rights reserved.

Effects of Managed Health Care/Formularies: Job Difficulty Pharmacists • Almost nine in ten pharmacists say their jobs are more difficult now compared to 5 years ago. • They attribute much of the difficulty to drug formularies.

Causes of Job Difficulty

Job Difficulty vs. Five Years Ago 4% Much/Somewhat Easier

9% About The Same

42% Much More Difficult

92% 29%

92%

87% Somewhat

39%

36%

36% 63%

53%

51%

45% Somewhat More Difficult

30% 6%

The move toward drug formularies

Q820. Compared to 5 years ago, would you say that overall your job has become….? Base: 5 Years in a Retail Setting Q825. To what extent is this due to each of the following? Base: Job Has Become Somewhat/Much More Difficult Page 69

A Great Deal

Harris Interactive Inc.

Multi-tier drug plans

Rising out-ofpocket costs for consumers

More alert consumers

Job Difficulty vs. Five Years Ago – by Years in Practice Pharmacists • Pharmacists say their jobs are more difficult compared to five years ago, regardless of how long they have been practicing. Job Somewhat/Much More Difficult 88%

88%

90%

84%

Total (a)

Less than 10 Years (b)

11 - 22 Years (c)

# Years in Practice Q820. Compared to 5 years ago, would you say that overall your job has become….? Base: 5 Years in a Retail Setting (n=856) Page 70

Harris Interactive Inc.

23 Years or More (d)

Changes in Professional Activities as a Result of Multi-Tier Drug Plans Pharmacists • Pharmacists spend more time now performing some of the activities they least prefer. Percent Who Spend Somewhat/Much More Time on Each Task Than They Did Before These Plans became Widespread

Ideal Rank

Communicating with/educating patients on their drug benefits, etc.

83

3

Communicating with health plans/insurers about patients’ drug benefits, including required paperwork

82

6

Communicating with physicians about patients’ drug benefits

73

4*

Performing administrative tasks including order entry, bookkeeping, managing staff, etc.

31

4*

Filling prescriptions including compounding, counting/measuring doses, labeling, controlled substance reporting, checking for interactions, etc.

28

2

Communicating with/educating patients on treatments, dosages, how to take medications, etc.

27

1

* Indicates a tie Q800/801. Have multi-tier drug plans caused you to spend less time, about the same, or more time on each of the following tasks than you did before such plans became widespread? Base: 5 Years in Retail Setting (n=856) Q405/406. Now rank each of the following activities in terms of how much time you would ideally like to spend on them, where 1 = “spend most time performing” and 6 = “spend least time of amount on.” Base: All Qualified Respondents (n=1001) Page 71

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Health Plans Today vs. Five Years Ago Pharmacists • Half of pharmacists say that working with today’s health plans is much more difficult compared to the typical plan 5 years ago.

Today’s Health Plans vs. Five Years Ago

Much More Difficult 51%

Somewhat/Much Easier 8%

Somewhat More Difficult 34%

Stayed About The Same 7%

Q815. Comparing the current typical health plan to the typical plan 5 years ago, would you say that working with these plans has become…..? Base: 5 Years in Retail Setting (n=856) Page 72

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Health Plans Today vs. Five Years Ago – by Years in Practice Pharmacists • Pharmacists who have practiced for 11 or more years are more likely to agree that today’s health plans are more difficult than the typical plan 5 years ago. Today’s Plans are Somewhat/Much More Difficult 87%

85% 78%

Total (a)

87%

c,d

Less than 10 Years (b)

11 - 22 Years (c)

23 Years or More (d)

# Years in Practice Q815. Comparing the current typical health plan to the typical plan 5 years ago, would you say that working with these plans has become…..? Base: 5 Years in Retail Setting (n=856) Page 73

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Effects of Co-pay Plans on Job Pharmacists • Three in four pharmacists say that dealing with co-pay plans interferes with their ability to do their jobs.

Dealing with these co-pay plans really interferes with my ability to do my job

73%

All in all, drug co-pay plans have not had much of an impact on how I do my job

Not Sure

24%

3%

Q910/915. Below are several pairs of statements. For each pair, please select the statement that more closely matches your opinion. Base: All Qualified Respondents (n=1001) Page 74

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Non-Compliance and Drug Selection Based on Patient Out-of-Pocket Costs

Pharmacists

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Patient Comments About High Out-of-Pocket Cost of Medications Pharmacists • Eight in ten pharmacists report that patients make frequent comments about the high out of pocket costs they pay for their covered medications.

Frequency of Comments

Frequently 79%

Occasionally 18%

Seldom 2%

Q520. Thinking about the patients you serve who have drug coverage, how often do you hear patients comment about the high out-of-pocket costs they have to pay for their covered medications? Base: All Qualified Respondents (n=1001) Page 76

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Patient Comments About High Out-of-Pocket Cost of Medication – by Therapeutic Class Pharmacists

Most Frequently Filled

Drugs for Which OOP Cost Most Likely to be Questioned*

Est. Mean OOP Cost at Which Patients Begin to Question*

Psychotherapeutics – Antianxiety

30

8

$20 - $25

Psychotherapeutics – Antidepressants

64

51

$25 - $30

Psychotherapeutics – Antipsychotics

5

20

$25 - $30

Psychotherapeutics – Other

1

2

--

Vascular agents - ARBs, including ACEs

44

33

$25 - $30

Vascular agents - Alpha blockers, Beta blockers, Alpha-beta blockers

31

9

$25 - $30

Vascular agents – CCBs

4

4

$20 - $25

Vascular agents - Other

1

2

--

Oral systemic anti-infectives

42

52

$25 - $30

Analgesics

61

13

$20 - $25

Hormones

25

12

$20 - $25

Respiratory therapy

12

11

$20 - $25

Q345. For which 5 classes of drugs do you most frequently fill prescriptions? Q525. In your experience, for which 5 classes of drugs are patients most likely to question their out-of-pocket costs for their covered prescriptions? Q531. Thinking about the drug classes you just selected, at what amount do patients begin to question their out-of-pocket costs for a 30 day supply of these medications? Base: All Qualified Respondents (n=1001) *Base: Patients Question Drug Costs Most frequent responses indicated in Red Page 77

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Patient Comments About High Out-of-Pocket Cost of Medication – by Therapeutic Class Pharmacists

Most Frequently Filled

Drugs for Which OOP Cost Most Likely to be Questioned*

Est. Mean OOP Cost at Which Patients Begin to Question*

Gastrointestinal

25

50

$25 - $30

Antiarthritics

10

33

$25 - $30

Antihyperlipidemics

30

48

$25 - $30

Diabetes therapy

48

22

$25 - $30

Diuretics

7

*

--

Neurologic – Anti-seizure medications

8

6

$25 - $30

Neurologic – Neuralgia

6

7

$25 - $30

Neurologic – Alzheimer’s disease/Dementia

1

18

$30 - $35

Neurologic – Other

2

1

--

Thyroid therapy

18

1

--

Antihistamines

17

31

$20 - $25

Cardiac agents – Coronary vasodilators

5

4

$25 - $30

Cardiac agents – Positive inotropic agent

1

2

--

Oral anti-fungal agents

*

30

$30 - $35

Genitourinary

1

1

--

Q345, Q525, Q531 continued Page 78

* Less than 1%

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-- cannot be determined due to small n (<25)

Responding To Patient Inquiries About Out-of-Pocket Medication Costs Pharmacists • Pharmacists are most likely to let the patient take action.

Likelihood of Taking Action 83%

82%

76%

Very Likely 62%

51%

43%

Somewhat Likely 46%

32% 20%

16%

32%

39%

44%

42%

25%

8% 30% 17%

Suggest Let patient Call doctor to Suggest patient call decide w hat request less patient call the health to do expensive doctor plan drug

Call health Ask health plan about plan cover less drug or low er expensive co-pay drugs

Q535/536. When a patient questions the amount he or she has to pay for a prescription, how likely are you to do each of the following? Base: Patients Question Drug Costs (n=999) Page 79

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Perceived Patient Non-Compliance in Order to Save Money Pharmacists • Pharmacists believe patients use a variety of money-saving strategies. Average cost at which patients begin to delay or refuse to get a prescription filled: $34.6

Perceived Frequency of Non-Compliant Behaviors 65% 57%

33%

26%

Ve ry O f t e n

56%

24%

S o m e wh a t O f t e n 39%

12% 32%

31%

32%

27%

Take less Take smaller Delay getting a Decide not to frequently than doses than prescription get a prescribed prescribed filled prescription filled

38%

14% 24%

Split tablets w ithout doctor's permission

Q600/601. To the best of your knowledge, how often do patients with drug coverage do each of the following in order to reduce or avoid out-of-pocket costs for prescription drugs? Base: All Qualified Respondents (n=1001) Page 80

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Perceived Patient Non-Compliance in Order to Save Money by Therapeutic Drug Class Pharmacists Drugs For Which OOP Cost Most Likely to be Questioned

Drugs For Which Patients Most Likely to be Non-compliant

Psychotherapeutics – Antianxiety Psychotherapeutics – Antidepressants Psychotherapeutics – Antipsychotics Psychotherapeutics – Other

8 51 20 2

9 41 20 3

Vascular agents - ARBs, including ACEs Vascular agents - Alpha blockers, Beta blockers, Alpha-beta blockers Vascular agents – CCBs Vascular agents - Other

33

32

9 4 2

15 7 4

Oral systemic anti-infectives Analgesics Hormones Respiratory therapy

52 13 12 11

30 16 18 10

Most frequent responses indicated in red. Q525. In your experience, for which 5 classes of drugs are patients most likely to question their out-of-pocket costs for their covered prescriptions? Base: Patients Question Drug Costs (n=999) Q610. In your experience, which of the 5 drug classes are patients most likely to be noncompliant in order to reduce out-of-pocket costs for prescription drugs? Base: Suspect Patients Are Non-Compliant (n-997) Page 81

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Perceived Patient Non-Compliance in Order to Save Money by Therapeutic Drug Class (cont.) Pharmacists Patients Most Likely to Question OOP Cost

Patients Most Likely to be Non-compliant

Gastrointestinal Antiarthritics Antihyperlipidemics Diabetes therapy Diuretics

50 33 48 22 *

43 32 54 20 4

Neurologic - Anti-seizure medications Neurologic – Neuralgia Neurologic - Alzheimer’s disease/Dementia Neurologic – Other

6 7 18 1

2 8 16 2

Thyroid therapy Antihistamines

1 31

2 41

Cardiac agents - Coronary vasodilators Cardiac agents - Positive inotropic agent Oral anti-fungal agents Genitourinary

4 2 30 1

4 * 29 1

Q525, Q610 continued Page 82

Most frequent responses indicated in red.

* Less than 1%

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-- cannot be determined due to small n (<25)

Perceived Health Outcomes of Patient Non-Compliance Pharmacists • Majorities of pharmacists believe it is common for patients to visit the doctor or urgent care facilities as a result of using non-compliant strategies to save money.

78%

25%

Health Outcomes Due to NonCompliance in Order to Save Money

Very Com m on 54%

Som ew hat Com m on 36%

13% 53%

Additional visits to a doctor

13%

41%

32%

Visits to an urgent care facility

Visits to a hospital em ergency room

29%

6% 23% Being adm itted to a hospital

Q615/616. As a result of patients being non-compliant to reduce their out-of-pocket costs for prescription drugs, how common or rare do you believe it is for them to experience health outcomes that result in……? Base: Suspect Patients Are Non-Compliant (n=997)

Page 83

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Perceived Impact of Insurance Restrictions on Drug Selection Pharmacists • Nine in ten pharmacists believe patients take sub-optimal medications due to insurance restrictions. % Who Suspect Patients Take Less-than-Optimal Medications Due To Insurance Restrictions

Yes 90% No 10%

Q700. Do you ever suspect that your patients with drug coverage end up taking less-than-optimal medications because of insurance restriction s? Base: All Qualified Respondents (n=1001) Page 84

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Perceived Effects of OOP Cost-Based Drug Selection Pharmacists • Majorities agree it is at least somewhat common for medications selected on the basis out-ofpocket cost to patients to be ineffective or cause negative side effects.

Effects of Cost-Based Drug Selection

Drug Not Effective

41%

48%

38%

10%

Very Common

Somewhat Common

Drug Causes Negative Side Effects

Somewhat Rare

33%

9%

6%

Very Rare

Very Common

9%

Somewhat Common

Q715/716. In your experience, how common or rare is it that the substituted medication……? Base: Patient Taking Less Than Optimal Medications (n=902)

Page 85

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Somewhat Rare

Very Rare

Perceived Health Outcomes of OOP Cost-Based Drug Selection Pharmacists • Majorities believe it is common for patients to make additional doctor visits as a result of costbased prescribing due to insurance restrictions. 64%

Results of Cost-Based Drug Selection

17%

Very Common Somewhat Common 47%

22% 2%

16% 2%

8%

20% 14%

1% 7%

Make additional visits to a doctor

Visit an urgent care facility

Visit a hospital emergency room

Be admitted to a hospital

Q720/721. As a result of substituting the doctor’s first choice drug with one that is covered or less expensive under the patient’s drug plan, how common do you think it is for patients to………..? Base: Patient Taking Less Than Optimal Medications Page 86

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