title: Lessons from the leucovorin shortages between 2009 and 2012 in a medicare advantage population: where do we go from here?
abstract: BACKGROUND
  Three distinct shortages of the generic drug leucovorin, a reduced form of folic acid used in several chemotherapy regimens, were reported by the US Food and Drug Administration (FDA) between 2008 and 2014. Levoleucovorin, an alternative therapy to leucovorin, failed to demonstrate superiority over leucovorin in clinical trials and is substantially more expensive.
  
  
  OBJECTIVE
  To calculate the impact of the leucovorin shortages on primary treatment costs to patients and a health plan, and to present strategies for health plans to deal with future drug shortages.
  
  
  METHODS
  This retrospective descriptive study was conducted using Humana's Medicare Advantage prescription drug plan administrative claims database between January 1, 2009, and December 31, 2012. A total of 1542 patients with at least 1 medical or pharmacy claim for either leucovorin or levoleucovorin during the first 3 months of the respective plan year (between 2009 and 2012) who had continuous enrollment for the entirety of the same plan year, were included in this study. Trends in primary treatment costs-defined as the drug cost of leucovorin or levoleucovorin-over the 4-year evaluation period were assessed. The mean annual patient out-of-pocket (OOP) costs and the mean plan-paid per member per month (PMPM) costs were also calculated.
  
  
  RESULTS
  The percentage of patients receiving leucovorin decreased annually, with a 15.8% drop from 2010 to 2011. This reduction was accompanied by a 6.6% increase in patients receiving levoleucovorin. The mean annual patient OOP costs were $167 to $714 higher for levoleucovorin than for leucovorin. Similarly, the mean plan-paid PMPM costs were higher (up to $1667 PMPM) for levoleucovorin than for leucovorin. The aggregate costs for the 2 drugs increased steadily, including the patient OOP costs and the plan-paid PMPM costs. The most prominent cost increase occurred between 2010 and 2011, with a 3.8-fold increase in patient OOP costs and a 5-fold increase in the plan-paid PMPM costs. This corresponded to the timing of the second leucovorin shortage announcement by the FDA in June 2010.
  
  
  CONCLUSIONS
  Health plans can play an important role in minimizing the impact of drug shortages by identifying the affected patient population, identifying therapeutic alternatives, assisting providers with alternative sourcing strategies when possible, adjusting approval processes, and implementing quality management or pathway programs.
authors.affiliation: Clinical Pharmacist, Humana Inc, Louisville, KY.
authors.forename: Mary S
authors.initials: MS
authors.lastname: Hayes
authors.affiliation: Clinical Pharmacist, Humana, Inc, Louisville, KY, at the time this work was completed.
authors.forename: Melea A
authors.initials: MA
authors.lastname: Ward
authors.affiliation: Researcher, Comprehensive Health Insights, Humana Inc, Louisville, KY.
authors.forename: S Lane
authors.initials: SL
authors.lastname: Slabaugh
authors.affiliation: Researcher, Comprehensive Health Insights, Humana Inc, Louisville, KY.
authors.forename: Yihua
authors.initials: Y
authors.lastname: Xu