Medicare: Considerations for Adding a Prescription Drug Benefit
(Testimony, 06/23/99, GAO/T-HEHS-99-153).

Pursuant to a congressional request, GAO discussed: (1) the factors
contributing to the growth in prescription drug spending for both the
general population and Medicare beneficiaries and efforts to control
that growth; and (2) benefit design and implementation issues to be
considered in deliberations about adding a new prescription drug benefit
to the Medicare Program.

GAO noted that: (1) proposals to add prescription drug coverage to
Medicare's benefits come during a period of rapid growth in national
spending for pharmaceuticals and transformations in the prescription
drug market; (2) increased coverage of drugs by health plans and
insurers, advances in drug treatments, and aggressive marketing have
spurred the growth in the use of pharmaceuticals, while the use of
formularies, pharmacy benefit managers, and generic substitutions as
cost control approaches have dramatically changed the nature of the
market in which prescription drugs are purchased; (3) what remains
unchanged since 1965, however, is the absence of coverage for outpatient
prescription drugs by traditional Medicare; (4) a third of the Medicare
population lacks the supplemental drug coverage provided to most
beneficiaries through employer-sponsored plans, managed care
organizations, Medicaid, or Medigap insurance; (5) moreover, high drug
utilization among the Medicare population translates into a potentially
daunting financial burden; (6) the implications of adding prescription
drug coverage to Medicare's benefit package depend on the choices made
regarding details such as its scope and financing; (7) its design and
implementation will also shape the impact of this benefit on
beneficiaries, Medicare spending, and the pharmaceutical market; (8)
recent experience provides at least two approaches for implementing a
drug benefit; (9) one would involve the Medicare program obtaining price
discounts from manufacturers; (10) such an arrangement could be modelled
after Medicaid's drug rebate program; (11) while the discounts in
aggregrate would likely be substantial, this approach lacks the
flexibility to achieve the greatest control over spending; (12) it
cannot effectively influence or steer utilization because it does not
include incentives that would encourage beneficiaries to make
cost-conscious decisions; (13) the second approach would draw from
private sector experience in negotiating price discounts from
manufacturers in exchange for shifting market share; (14) some plans and
insurers employ pharmacy benefit managers to manage their drug benefits,
including claims processing, negotiating with manufacturers,
establishing lists of drug products that are preferred because of price
or efficacy, and developing beneficiary incentive approaches to control
spending and use; and (15) applying these techniques to the Medicare
program would be difficult due to its size, the need for transparency in
its actions, and the imperative for equity for its beneficiaries.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-99-153
     TITLE:  Medicare: Considerations for Adding a Prescription Drug
	     Benefit
      DATE:  06/23/99
   SUBJECT:  Prices and pricing
	     Health care programs
	     Health insurance
	     Health resources utilization
	     Health insurance cost control
	     Pharmaceutical industry
	     Drugs
	     Cost analysis
IDENTIFIER:  Medigap
	     Medicare Choice Program
	     Medicare Program
	     Medicaid Program

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Cover
================================================================ COVER

Before the Committee on Finance, U.S.  Senate

For Release on Delivery
Expected at 10:00 a.m.
Wednesday, June 23, 1999

MEDICARE - CONSIDERATIONS FOR
ADDING A PRESCRIPTION DRUG BENEFIT

Statement of Laura A.  Dummit, Associate Director
Health Financing and Public Health Issues
Health, Education, and Human Services Division

GAO/T-HEHS-99-153

GAO/HEHS-99-153T

(101865)

Abbreviations
=============================================================== ABBREV

  BBA - Balanced Budget Act of 1997
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  HMO - health maintenance organization
  OBRA - Omnibus Budget Reconciliation Act of 1990
  PBM - pharmacy benefit manager

MEDICARE:  CONSIDERATIONS FOR
ADDING A PRESCRIPTION DRUG BENEFIT
============================================================ Chapter 0

Mr.  Chairman and Members of the Committee: 

I am pleased to be here today as you consider a prescription drug
benefit for Medicare beneficiaries.  Over the past several months,
this Committee has held a series of hearings on Medicare reform
issues to determine the nature and extent of changes needed to
modernize the program and control its impact on the federal budget. 
These discussions come at an important juncture in the program's
historythe Congress passed landmark legislation in the Balanced
Budget Act of 1997 (BBA) that has the potential to improve the
financial underpinnings of the program.  Yet, more work remains to
ensure Medicare's continued financial viability.  Budget projections
show health care consuming ever-larger shares of the federal dollar,
thus threatening to crowd out funding for other valued government
programs and activities.  At the same time, many believe that
Medicare's current benefit structure should be updated to include a
prescription drug benefit. 

Studies suggest that broadening Medicare coverage to include
prescription drugs could add between 7.2 and 10 percent to Medicare
costs.  Such an expansion would occur at a time when Medicare's rolls
are growing and are projected to increase rapidly with the aging of
the baby boom generation and during a time of major technological
advances in medicine and biotechnology.  Currently, some Medicare
beneficiaries face a significant financial burden for outpatient
prescription drugs.  The policy dilemma before you today is that, on
the one hand, Medicare's lack of a prescription drug benefit may
impede access to certain treatment advances, whereas on the other,
the cost implications of including a prescription drug benefit will
be substantial.  These additional costs would serve to erode the
projected financial condition of the Medicare program, which,
according to the Medicare trustees, is already unsustainable in its
present form. 

My remarks today will focus on the factors contributing to the growth
in prescription drug spending for both the general population and
Medicare beneficiaries and efforts to control that growth.  I will
also discuss benefit design and implementation issues to be
considered in deliberations about adding a new prescription drug
benefit.  My comments are based on analyses of recent data and our
body of completed work on prescription drugs. 

In summary, proposals to add prescription drug coverage to Medicare's
benefits come during a period of rapid growth in national spending
for pharmaceuticals and transformations in the prescription drug
market.  Increased coverage of drugs by health plans and insurers,
advances in drug treatments, and aggressive marketing have spurred
the growth in the use of pharmaceuticals, while the use of
formularies, pharmacy benefit managers, and generic substitutions as
cost control approaches have dramatically changed the nature of the
market in which prescription drugs are purchased. 

What remains unchanged since 1965, however, is the absence of
coverage for outpatient prescription drugs by traditional Medicare. 
A third of the Medicare population lacks the supplemental drug
coverage provided to most beneficiaries through employer-sponsored
plans, managed care organizations, Medicaid, or Medigap insurance. 
Moreover, high drug utilization among the Medicare population
translates into a potentially daunting financial burden. 

The implications of adding prescription drug coverage to Medicare's
benefit package depend on the choices made regarding details such as
its scope and financing.  Its design and implementation will also
shape the impact of this benefit on beneficiaries, Medicare spending,
and the pharmaceutical market.  Recent experience provides at least
two approaches for implementing a drug benefit.  One would involve
the Medicare program obtaining price discounts from manufacturers. 
Such an arrangement could be modeled after Medicaid's drug rebate
program.  While the discounts in aggregate would likely be
substantial, this approach lacks the flexibility to achieve the
greatest control over spending.  It cannot effectively influence or
steer utilization because it does not include incentives that would
encourage beneficiaries to make cost-conscious decisions.  The second
approach would draw from private sector experience in negotiating
price discounts from manufacturers in exchange for shifting market
share.  Some plans and insurers employ pharmacy benefit managers
(PBM) to manage their drug benefits, including claims processing,
negotiating with manufacturers, establishing lists of drug products
that are preferred because of price or efficacy, and developing
beneficiary incentive approaches to control spending and use. 
Applying these techniques to the Medicare program, however, would be
difficult due to its size, the need for transparency in its actions,
and the imperative for equity for its beneficiaries. 

   MANY FACTORS HAVE SPURRED
   PRESCRIPTION DRUG SPENDING AND
   FOSTERED MARKET CHANGES
---------------------------------------------------------- Chapter 0:1

Extensive research and development over the past 10 years have led to
the introduction of new prescription drug therapies and improvements
over existing therapies that, in some instances, have replaced other
health care interventions.  The growing importance of prescription
drugs as part of health care has made the inclusion of drug benefits
an attractive policy feature to consumers with a choice among health
insurance products.  Most commercial private health insurance
products, Medicare+Choice\1 plans, and all Medicaid programs provide
their beneficiaries with an outpatient prescription drug benefit. 
Health plans have found that including prescription drugs as a
covered benefit helps attract members and is valuable to their
beneficiaries.  Prescription drug expenditures have outpaced other
components of health care spending in recent years due to several
factors.  At the same time, the use of new approaches to dampen these
expenditures is reshaping the prescription drug market. 

--------------------
\1 As an alternative to traditional Medicare fee-for-service,
beneficiaries in Medicare+Choice plans (formerly Medicare risk health
maintenance organizations) obtain all their services through a
managed care organization and Medicare makes a monthly capitation
payment to the plan on their behalf. 

      RISE IN PRESCRIPTION DRUG
      SPENDING
-------------------------------------------------------- Chapter 0:1.1

Over the past 5 years, prescription drug expenditures have grown
significantly, both in total and as a share of all health
expenditures.  Prescription drug spending grew, on average, from 1992
to 1997 by 11 percent a year compared with a 5 percent average growth
rate for health expenditures overall.  (See table 1.) Drug spending
during that same period also consumed a larger share of total health
care spendingrising from 5.6 percent to 7.2 percent. 

                          Table 1
          
           National Expenditures on Prescription
                       Drugs, 1992-97

                             Annual growth
                                        in   Annual growth
              Prescription    prescription   in all health
                      drug            drug            care
              expenditures    expenditures    expenditures
Year         (in millions)       (percent)       (percent)
----------  --------------  --------------  --------------
1997               $78,888              14               5
1996                69,111              13               5
1995                61,060              11               5
1994                55,189               9               5
1993                50,632               9               7
1992                46,598              11               9
Average                                 11               5
 annual
 growth,
 1992-97
----------------------------------------------------------
Source:  Health Care Financing Administration (HCFA), Office of the
Actuary. 

While total drug expenditures depend both on the prices paid and the
volume used, the recent spending increases appear to have more to do
with stepped up volume than price.  A precise determination of how
much is due to volume versus price increases is not possible since
only data on the retail pharmaceutical prices are widely available. 
The actual prices paid are often lower than retail levels, as
insurers, PBMs, and other purchasers negotiate significant discounts
from manufacturers and other suppliers.  Market changes in recent
years have likely altered the size of those discounts. 

Several factors have contributed to increased prescription drug use
and the resulting spending increases:  namely, more individuals have
third-party drug coverage, new drug therapies have been introduced
into the market, and manufacturers have marketed drugs more
aggressively through advertising directly to consumers. 

The increase in private insurance coverage for prescription drugs is
a likely factor accounting for the rise in utilization.  In the
decade between 1987 and 1997, the share of prescription drug
expenditures paid by private health insurers rose from almost a third
to more than half.  (See fig.  1.) The development of new, more
expensive drug therapies--including new drugs that replace old drugs
and new drugs that treat disease more effectively--also contributed
to the drug spending growth.  The average number of new drugs
entering the market each year has grown from 24 at the beginning of
the 1990s to 33 now.  Similarly, biotechnology advances and a growing
knowledge of the human immune system are significantly shaping the
discovery, design, and production of drugs.  Advertising pitched to
the lay consumer has also likely upped consumers' use of prescription
drugs.  Between March 1998 and March 1999, industry spending on
advertising grew 16 percent, to $1.5 billion. 

   Figure 1:  Comparison of
   National Drug Expenditures,
   1987 and 1997

   (See figure in printed
   edition.)

\a Out-of-pocket expenditures include direct spending by consumers
for all health care goods and services, such as coinsurance,
deductibles, and any amounts not covered by insurance.  Out-of-pocket
premiums paid by individuals are not counted here. 

Source:  Health Care Financing Administration, Office of the Actuary. 

      CURRENT MEDICARE BENEFICIARY
      DRUG COVERAGE
-------------------------------------------------------- Chapter 0:1.2

Prescription drugs are an important component of medical care for the
elderly because of the greater prevalence of chronic and other health
conditions associated with aging.  In 1995, Medicare beneficiaries
had on average more than 18 prescriptions filled.  This varies
substantially across beneficiaries, however, reflecting the presence
of chronic and other conditions that respond to drug treatment and
also financial considerations such as third-party prescription drug
coverage.  In 1995, annual drug costs were $600 for the elderly,
compared to just over $140 for the nonelderly population.  For some,
spending is considerably higher.  In 1999, an estimated 20 percent of
Medicare beneficiaries will have total drug costs of $1,500 or
more--a substantial sum for those lacking some form of insurance to
subsidize the purchase. 

This financial burden is due, in part, to gaps in insurance coverage
for prescription drugs.  One third of the Medicare population lacks
drug coverage altogether.  Those with third-party protections often
face deductibles, cost sharing, or limits on total benefit payments. 
The vast majority of the approximately 17 percent of Medicare
beneficiaries enrolled in a Medicare+Choice plan have drug coverage,
as do retirees who have employer-sponsored insurance.  All
beneficiaries who are enrolled in Medicaid receive drug coverage. 
Other beneficiaries may purchase Medigap policies that provide drug
coverage, although Medigap policies involve significant cost sharing,
impose annual limits, may contain significant exclusions, and can be
expensive.  A Medigap policy with drug coverage can cost $1,500 more
per year than an otherwise comparable policy. 

Medicare beneficiaries with drug coverage use more prescription drugs
and have higher overall drug expenditures than those without drug
coverage.  This may be because beneficiaries with higher prescription
drug needs may be more likely to obtain third-party protections. 
Alternatively, the lack of coverage for some may inhibit appropriate
drug utilization. 

      COST CONTROL APPROACHES
      RESHAPING PHARMACEUTICAL
      MARKET
-------------------------------------------------------- Chapter 0:1.3

During this period of growth in the volume of prescription drugs
used, third-party payers, which have been the primary purchasers,
have pursued various approaches to controlling spending.  These
efforts have initiated a transformation of the pharmaceutical market. 
A world in which insured individuals purchase drugs at retail
pharmacies at retail prices and then seek reimbursement is giving way
to third-party payers influencing which drug is purchased, how much
is paid for a drug, and where it is purchased. 

A common technique to manage pharmacy care and control costs is to
use a formulary.  A formulary is a list of prescription drugs,
grouped by therapeutic class, that a health plan or insurer prefers
and may encourage to be prescribed for its enrollees.  Decisions
about which drugs to include on a formulary are based on their
medical value and their price.  Both inclusion of a drug on a
formulary and its cost can affect how frequently it is prescribed and
purchased and, therefore, can affect its market share. 

Formularies can be open, incentive-based, or closed.  Open
formularies are often referred to as voluntary because enrollees
are not penalized if their physicians prescribe nonformulary drugs. 
Incentive-based formularies generally offer enrollees lower
copayments for the preferred formulary or generic drugs. 
Incentive-based or managed formularies are becoming more popular
because they combine flexibility and greater cost-control features
than open formularies.  A closed formulary limits insurance coverage
to formulary drugs only and requires enrollees to pay the full cost
of nonformulary drugs prescribed by their physician. 

Many health plans or insurers also contract with a PBM to administer
and manage their prescription drug benefit.  PBMs offer a range of
services, including prescription claims processing, mail-service
pharmacy, formulary development and management, pharmacy network
development, generic substitution incentives, and drug utilization
review.  PBMs have successfully negotiated discounts and rebates on
prescription drugs with manufacturers. 

   ISSUES TO CONSIDER IN BENEFIT
   DESIGN AND ADMINISTRATION
---------------------------------------------------------- Chapter 0:2

Policymakers considering proposals for including a prescription drug
benefit in the Medicare program are facing a myriad of options. 
Assessing the merits of whether and how to implement these reforms
will depend, in large measure, on whom the benefit covers and how it
is financed.  In such an assessment, it may be appropriate to recall
the criteria that the Comptroller General enunciated before this
Committee in testimony on March 10.  These criteria could guide
deliberations on expanding coverage to include prescription drugs: 
(1) affordability--a benefit should be evaluated in terms of its
impact on the sustainability of program expenditures for the long
term; (2) equity--a benefit should be fair across groups of
beneficiaries and to providers; (3) adequacy--a benefit should foster
cost-effective and clinically meaningful innovations, furthering
Medicare's tradition of technology development; (4) feasibility--a
benefit should incorporate such administrative essentials as
implementation and monitoring techniques; and (5) acceptance--a
benefit should account for the need to educate beneficiary and
provider communities about its costs and the realities of trade-offs
required when significant policy changes occur. 

Although the Congress will likely examine a number of alternative
benefit designs and administrative options, I would like to briefly
discuss two approaches that may be considered.  One would be similar
to how drug benefits are provided in state Medicaid programs, which
rely on federal authority to lower drug prices through rebates paid
by drug manufacturers to control spending.  The other would be
modeled after approaches adopted by private sector health plans in
which PBMs are typically used to administer various techniques to
control pharmacy benefit costs.  Each approach has some advantages
and disadvantages. 

      MEDICAID PROGRAMS RELY ON
      DISCOUNTS, LIMITED
      UTILIZATION CONTROLS
-------------------------------------------------------- Chapter 0:2.1

Before the enactment of the Medicaid drug rebate program as part of
the Omnibus Budget Reconciliation Act of 1990 (OBRA), state Medicaid
programs paid close to retail prices for outpatient drugs.  As the
largest government payer for prescription drugs, Medicaid drug
expenditures comprised about 13 percent of the domestic
pharmaceutical market.  Other purchasers, such as health maintenance
organizations (HMO) and hospitals, negotiated discounts with
manufacturers and paid considerably less. 

The rebate program required drug manufacturers to give state Medicaid
programs rebates for outpatient drugs.  The rebates were based on the
lowest or best prices they charged other purchasers.  In return for
the rebates, state Medicaid programs maintain open formularies that
permit reimbursement for all drugs manufactured by pharmaceutical
companies that entered into rebate agreements with the Health Care
Financing Administration. 

After the rebate program's enactment, a number of market changes
occurred that affected other purchasers of prescription drugs and the
amount of the rebates Medicaid programs received.  For example, the
prices many large private purchasers, such as HMOs, paid for
outpatient drugs increased substantially.  Moreover, the lowest
prices in the market increased faster than the drugs' average prices
as drug manufacturers significantly reduced the price discounts they
offered private purchasers.  As a result, within 2 years the rebates
paid to state Medicaid programs fell to the minimum amount required
by OBRA. 

Although states have received billions of dollars in rebates from
drug manufacturers since the enactment of OBRA 1990, state Medicaid
directors have expressed concerns about the rebate program.  The
principal concern involves OBRA's requirement for open formularies,
which limits the utilization controls Medicaid programs can use at a
time when prescription drug expenditures are rapidly increasing. 
Although they can require recipients to obtain prior authorization
for particular drugs and impose monthly limits on the number of
covered prescriptions, other techniques to steer recipients to less
expensive drugs are not available to them.  These approaches can add
to the administrative burden on state Medicaid programs, lead to
purchasing more expensive drugs, and create access problems for
certain individuals. 

      OTHER PAYERS EMPLOY VARIOUS
      TECHNIQUES TO CONTROL
      EXPENDITURES
-------------------------------------------------------- Chapter 0:2.2

Other payers, such as private employer health plans, Medicare+Choice
plans, and insurance products for federal employees have taken a
different approach to managing their prescription drug benefits. 
They use formularies and copayments to control drug utilization and
obtain better prices by concentrating purchases on selected drugs. 
In many cases, these plans or insurers retain the services provided
by a PBM to implement their pharmacy benefit. 

Beneficiary cost sharing has had a central role in attempting to
influence drug utilization.  Copayments frequently are structured to
both influence the choice of a drug and purchasing arrangements. 
While formulary restrictions can channel purchases to preferred
drugs, closed formularies, which provide reimbursement only for
preferred drugs, have generated significant consumer dissatisfaction. 
As a result, many plans link their cost sharing requirements and
formulary lists.  The fastest growing trend today is to maintain an
open formulary in which all drugs receive some coverage, with
beneficiaries paying different levels of cost sharing for different
drugs--typically a smaller copayment for generic drugs, a larger one
for preferred drugs, and an even larger one for all other drugs. 
Reducing the required copayments may also encourage enrollees using
maintenance drugs for chronic conditions to use particular suppliers,
like a mail-order pharmacy. 

Plans and insurers have turned to PBMs for their expertise in
establishing formulary lists, negotiating prices with manufacturers
and suppliers, and processing beneficiary claims, as well as a
variety of clinical services, such as drug utilization review.  PBMs
bring expertise and economies of scale to these tasks that individual
plans or insurers may not have.  In addition, they often may have
more leverage than individual plans in negotiating prices as they
combine the purchasing power of multiple purchasers. 

Traditional fee-for-service Medicare has generally established
administrative prices for services like physician or hospital care
and then processed and paid claims with few utilization controls. 
Adopting some of the techniques used by private plans and insurers
might have the potential for better control of costs.  However, how
to adopt those techniques to deal with the unique characteristics and
enormity of the Medicare program raises many questions. 

Negotiated or competitively determined prices would be superior to
administered prices only if Medicare could employ some of the
utilization controls that come from having a formulary and
differential beneficiary cost sharing.  In this manner, Medicare
would be able to negotiate significantly discounted prices by
promising to deliver a larger market share for a manufacturers'
product.  Manufacturers would have no incentive to offer a deep
discount if all drugs in a therapeutic class were covered on the same
terms.  Without a promised share of the Medicare market, these
manufacturers may reap greater returns from higher prices and
concentrating marketing efforts on physicians and consumers to
influence prescribing patterns. 

Implementing a formulary and other utilization controls could prove
difficult for Medicare.  Developing a formulary involves determining
which drugs are therapeutically equivalent so that several from each
class can be selected as preferred.  Plans and PBMs currently make
those determinations privately--something that would not be tolerable
for Medicare, which must have transparent policies that are
determined openly.  Given the stakes involved in being selected, one
can imagine the intensive efforts to offer input to and scrutinize
the selection process. 

Medicare may also find it impossible to delegate this task to a PBM
or multiple PBMs.  A single PBM contractor would likely be subject to
the same level of scrutiny as the program.  Such scrutiny may
compromise the flexibility PBMs have utilized to generate savings. 
An alternative would be to grant flexibility to multiple PBMs that
are responsible only for a share of the market.  Contracting with
multiple PBMs, though, raises other issues.  If each PBM had
exclusive responsibility for a geographic area, beneficiaries who
need certain drugs could be advantaged or disadvantaged merely
because they live in a particular area.  If multiple PBMs operated in
each area, beneficiaries would choose one to administer their drug
benefit.  Then, how to inform beneficiaries of the differences in
each PBM's policies and the possible need to risk adjust payments to
PBMs for differences in health status of beneficiaries using them
would become issues. 

   CONCLUDING OBSERVATIONS
---------------------------------------------------------- Chapter 0:3

Adding prescription drug coverage to the Medicare program would have
a substantial impact on the costs of the program, in addition to the
financial well being and health of many of its beneficiaries.  The
challenge will be in designing and implementing drug coverage to
minimize the financial implications for Medicare while maximizing the
positive effect of such coverage on Medicare beneficiaries.  Most
importantly, this substantial benefit reform must be consistent with
efforts to ensure the sustainability of the program so that Medicare
does not consume an unreasonable share of our productive resources
and does not encroach on other public programs or private sector
activities.  Reconciling these needs will take the kind of leadership
and creativity demonstrated by the Congress as it designed and
implemented the BBA reforms that extended Medicare's financial
viability. 

It may also be instructive to return to lessons learned in
implementing the BBA reforms.  From those efforts, it is clear that
major changes to the Medicare program need to be effective, flexible,
and steadfast.  Effectiveness must include the collection of
necessary data to assess impact--separating the transitory from the
permanent and the trivial from the important.  Flexibility is
critical to make changes and refinements when conditions warrant and
when actual outcomes differ substantially from the expected ones. 
Steadfastness is needed when particular interests pit the primacy of
their needs against the more global interests of preserving Medicare. 

-------------------------------------------------------- Chapter 0:3.1

Mr.  Chairman, this concludes my prepared statement.  I will be happy
to answer any questions you or other Members of the Committee may
have. 

   GAO CONTACT AND
   ACKNOWLEDGEMENTS
---------------------------------------------------------- Chapter 0:4

For future contacts regarding this testimony, please call Laura A. 
Dummit at (202) 512-7119 or John Hansen at (202) 512-7105.  Other
individuals who made key contributions include Tricia Spellman,
Kathryn Linehan, and Hannah Fein. 

RELATED GAO PRODUCTS

Defense Health Care:  Fully Integrated Pharmacy System Would Improve
Service and Cost-Effectiveness (GAO/HEHS-98-176, June 12, 1998). 

Drug Prices:  Effects of Opening Federal Supply Schedule for
Pharmaceuticals Are Uncertain (GAO/HEHS-97-60, June 11, 1997). 

Pharmacy Benefit Managers:  FEHBP Plans Satisfied With Savings and
Services, but Retail Pharmacies Have Concerns (GAO/HEHS-97-47, Feb. 
1997). 

Pharmacy Benefit Managers:  Early Results on Ventures With Drug
Manufacturers (GAO/HEHS-96-45, Nov.  9, 1995). 

Medicaid:  Changes in Best Price for Outpatient Drugs Purchased by
HMOs and Hospitals (GAO/HEHS-94-194FS, Aug.  5, 1994). 

Prescription Drugs and the Elderly:  Many Still Receive Potentially
Harmful Drugs Despite Recent Improvements (GAO/HEHS-95-152, July 24,
1995). 

Prescription Drugs:  Spending Controls in Four European Countries
(GAO/HEHS-94-30, May 17, 1994). 

Prescription Drugs:  Companies Typically Charge More in the United
States Than in the United Kingdom (GAO/HEHS-94-29, Jan.12, 1994). 

Medicaid:  Outpatient Drug Costs and Reimbursements for Selected
Pharmacies in Illinois and Maryland (GAO/HRD-93-55FS, Mar.  18,
1993). 

Prescription Drug Prices:  Analysis of Canada's Patented Medicine
Prices Review Board (GAO/HRD-93-51, Feb.  17, 1993). 

Medicaid:  Changes in Drug Prices Paid by HMOs and Hospitals Since
Enactment of Rebate Provisions (GAO/HRD-93-43, Jan.  15, 1993). 

Prescription Drugs:  Companies Typically Charge More in the United
States Than in Canada (GAO/HRD-92-110, Sept.  30, 1992). 

Prescription Drugs:  Changes in Prices for Selected Drugs
(GAO/HRD-92-128, Aug.  24, 1992). 

Medicaid:  Changes in Drug Prices Paid by VA and DOD Since Enactment
of Rebate Provisions (GAO/HRD-91-139, Sept.  18, 1991). 

*** End of document. ***