Despite public knowledge of the harmful effects of

Transcription

1 Failure to Obtain Varenicline in Members With Pharmacy Benefits At a Glance Practical Implications e36 Author Information e40 Web Exclusive Original Research Catherine E. Cooke, PharmD, BCPS, PAHM; Elbert D. Glover, PhD; Shan Xing, PharmD; and Helen Y. Lee, PharmD, MBA Despite public knowledge of the harmful effects of smoking, 21% of US adults are current smokers and 79.8% of them smoke every day. 1 Quitting smoking has immediate and long-term benefits; smokers who remain abstinent reduce their risk for smoking-related diseases and improve their overall health. 2 Approximately 45% of smokers tried to quit at least once in the past year. 1 However, smoking is a highly addictive chronic behavior requiring repeated interventions; often the smoker needs to make multiple attempts to quit. 3 Quitting smoking is not easy, and only 3% to 5% of smokers who try to quit cold turkey without treatment maintain successful abstinence for at least 6 months. 4 Treatment options for smoking cessation include counseling and pharmacotherapy. Each is effective when used alone, but the combination is more effective. 3 Varenicline is 1 of 7 first-line medications to treat tobacco dependence recommended by the US Public Health Service. 3 Patients treated with a 12-week course of varenicline have a 33.2% estimated abstinence rate at 6 months, 3 which is about 2- to 3-fold higher than that for placebo. 5 In addition, varenicline had the highest estimated abstinence rate among monotherapy interventions including nicotine products and buproprion. 3 Side effects of varenicline include nausea, trouble sleeping, and abnormal, strange, or vivid dreams. In addition, there is a warning that suicide or suicidal ideation, depressed mood, agitation, and changes in behavior have been reported in patients attempting to quit smoking while using varenicline. Clinicians should inquire about their patient s psychiatric history before prescribing varenicline and monitor patients for psychiatric symptoms during use. 3 The 2008 update of the Treating Tobacco Use and Dependence clinical practice guideline published by the US Public Health Service recommends that clinicians encourage all patients to use effective medications for tobacco dependence when attempting to quit (barring contraindications). 3 However, only 22% of patients use cessation aids when trying to quit. 6 ABSTRACT Objective: To evaluate the rate of failure to obtain electronically prescribed (erx) varenicline and assess which factors predict failure. Study Design: Retrospective cohort. Methods: Members from a Mid-Atlantic managed care organization with electronic prescriptions for varenicline during 2008 were eligible for inclusion. Exclusion criteria were age less than 18 years on January 1, 2008, or lack of continuous enrollment in the same pharmacy benefi t plan from January 1, 2008, through February 15, Each electronic varenicline prescription was categorized as obtained or unobtained. The primary outcome was the rate of failure to obtain erx varenicline. Multivariate regression was used to determine the clinical, demographic, and prescription factors associated with failure. Results: The cohort consisted of 1556 electronic varenicline prescriptions, of which 1112 (71.5%) were obtained and 444 (28.5%) were not obtained. A total of 262 prescriptions (16.8% of the total prescription volume and 59.0% of the unobtained category) were reversed (ie, approved for coverage but not obtained by the patient). Of the 1282 study members, 362 (28.2%) failed to obtain varenicline. Signifi cant factors associated with failure to obtain varenicline were younger age, continuing therapy, and higher copayment. Conclusions: More than one-fourth of patients failed to obtain varenicline due to access barriers and overt nonadherence. Strategies to improve utilization of smoking cessation products such as follow-up from healthcare providers and payers, improved formulary coverage, and increased awareness of coverage should be used. (Am J Pharm Benefi ts. 2011;3(3):e35-e41) Vol. 3, No. 3 The American Journal of Pharmacy Benefi ts e35

2 n Cooke Glover Xing Lee PRACTICAL IMPLICATIONS More than one-fourth of patients from a Mid-Atlantic managed care organization did not obtain varenicline after it had been electronically prescribed. n Healthcare plans should encourage use of smoking cessation products by discussing the benefits of coverage with employer groups, informing members of coverage, and facilitating physician follow-up. n Electronic prescribing data allow an objective assessment of whether patients obtain the prescribed smoking cessation medication from the pharmacy. n Bidirectional feedback to the prescriber through electronic prescribing software allows for notification of the patient s failure to obtain the smoking cessation product. Most studies that have reported on the use of smoking cessation products have relied on patient self-report through questionnaires 7 and interviews. 6 The few studies that used pharmacy claims data required patients to have filled at least 1 prescription for a smoking cessation therapy. 8,9 There are few data on the actual rate at which patients fail to ever get their prescription filled, which is often referred to as the rate of first-fill failure. Obtaining the data to determine first-fill failure rates usually requires patient report or time-consuming chart reviews, unrealistic for large populations. A more efficient way is to use data from electronic prescribing, defined as the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network. 10 Using administrative and prescription data from a large managed care organization (MCO), we determined the rate at which electronically prescribed (erx) varenicline was not obtained by the patient and factors associated with failure of first fill. METHODS This retrospective study used administrative and pharmacy data from a mid-atlantic MCO serving 3.3 million medical members and 1.2 million pharmacy members. To be eligible for inclusion, the member had to have at least 1 erx varenicline prescription from January 1, 2008, through December 31, A pharmacy claims query identified all claims associated with varenicline prescriptions from January 1, 2008, through February 15, Members and their prescription claims were excluded if the member was younger than 18 years on January 1, 2008, or if the member did not have continuous enrollment in the same pharmacy benefit plan from January 1, 2008, through February 15, The pharmacy claims data set contained the following fields: unique de-identified patient number, patient age (as of January 1, 2008), patient sex, prescription number, date filled, drug name, drug strength, claim number, claim decision, claim status description, MCO paid quantity, copayment, and days supplied. For the claim decision, 2 options were possible: paid and denied. A paid claim meant that the prescription was approved by the MCO for coverage and the patient obtained the medication. A denied claim occurred when the prescription product was not provided to the member and the member did not obtain the medication. The claim status description included the reason for the claim decision. For denied prescriptions, one of the reasons listed in the claim status description was reversed, which meant that the prescription had originally been assigned a paid claim, but was later voided or reversed by the pharmacist and resulted in a denied claim with a claim status description of reversed. Reversed prescriptions are those that had been approved for coverage, but were subsequently reversed because the patient did not obtain the prescription. This may occur because patients fail to show up at the pharmacy to get their prescription, or decide when they get there that they do not want the prescription (eg, because of cost). When a patient fails to pick up the prescription, pharmacists are required to reverse a previously approved claim. The reversed category served as a proxy for overt patient nonadherence as patients had coverage for varenicline, but chose not to obtain their prescription. The pharmacy claims query captured all of the claims or attempts at adjudication for varenicline. Each erx varenicline prescription was matched to pharmacy claims data within 45 days of the erx date. Only first-fill claims within 45 days of each erx for a varenicline starter pack or continuing pack were examined; refills were not included. The starter pack contains 1 card of 11 tablets (0.5 mg) and 3 cards of 14 tablets (1 mg), while the continuing pack contains 4 cards of 14 tablets (1 mg). Each erx varenicline prescription was categorized as obtained or unobtained based on the claim decision of paid or denied, respectively. Prescriptions with no matching pharmacy claims were considered unobtained. For prescriptions with both paid and denied claims, decision rules were applied. If there was a paid claim for the same drug/strength within the days supply prior to this prescription or a paid claim within 45 days after the erx date, the e36 The American Journal of Pharmacy Benefits May/June 2011

3 prescription was classified as obtained. The time frame of 45 days was chosen to represent an appropriate amount of time during which a patient should have been able to obtain varenicline, given that there was no sampling of varenicline. Figure. Identification of Patient Cohort Members with at least 1 erx prescription for varenicline during 2008 n = 1828 (2074 prescriptions) Failure to Obtain Varenicline Excluded members younger than 18 years on January 1, 2008 Outcome Measures The primary outcome was the percentage of erx varenicline prescriptions that patients failed to obtain. To calculate this number, the numerator was the number of electronic prescriptions with no matching paid claim decisions, while the denominator was the overall number of erx varenicline prescriptions in the cohort. The secondary outcome measure examined the clinical and demographic factors (ie, age, sex, varenicline product, varenicline coverage, and copayment) related to failure to obtain erx varenicline. All data conformed to Health Insurance Portability and Accountability Act patient privacy standards, and the data set was delivered to the researchers with de-identified patient information. The University of Maryland, College Park Institutional Review Board fully approved the research protocol. Statistical Analysis Statistical analysis included descriptive statistics such as percentages for discrete variables (eg, sex) and calculations of means and standard deviations for continuous variables (eg, age). Univariate analyses examined the correlation between clinical/demographic factors and primary outcome rates. Binomial logistic regression determined whether there were any predictors of the failure rate. Statistical significance was set at an accepted alpha (P <.05). RESULTS Patient/Prescription Cohort During 2008, there were 1828 members with at least 1 electronic prescription for varenicline (Figure). Members younger than 18 years on January 1, 2008, and those without continuous medical and pharmacy coverage from January 1, 2008, through February 15, 2009, were Adults with at least 1 erx prescription for varenicline during 2008 n = 1817 (2063 prescriptions) Cohort for Primary Outcome Adults with at least 1 erx prescription for varenicline and continuous pharmacy coverage n = 1282 (1556 prescriptions) Cohort for Secondary Outcome Adults with at least 1 erx prescription for varenicline, continuous pharmacy coverage, and matching pharmacy claims n = 1225 (1472 prescriptions) erx indicates electronically prescribed. Excluded members without continuous pharmacy benefit coverage from 1/1/08 to 2/15/09 Excluded members without pharmacy claims for varenicline from 1/1/08 to 2/15/09) excluded. The final cohort consisted of 1282 adults, with approximately half being men (Table 1). The average age was 43.9 years. There were 1556 electronic prescriptions for varenicline, which equaled an average of 1.2 prescriptions per member. The starting month pack accounted for 1004 (64.5%) prescriptions; continuing therapy accounted for 552 (35.5%) prescriptions. Primary Outcome Of the 1556 electronic prescriptions for varenicline, 1112 (71.5%) were obtained and 444 (28.5%) were not obtained. A total of 262 prescriptions (16.8% of the total prescription volume and 59.0% of the unobtained prescription category) were reversed, a subcategory of unobtained prescriptions that represented varenicline prescriptions approved by the MCO for coverage, but that the patient chose not to obtain. Of the 1282 final cohort members, 362 (28.2%) failed to obtain varenicline. This group consisted of 17.2% (221/1282) of members who were able to obtain their prescription (ie, claim coded as reversed), and 11.0% (141/1282) who were denied coverage by the MCO. Vol. 3, No. 3 The American Journal of Pharmacy Benefits e37

4 n Cooke Glover Xing Lee Table 1. Prescription and Patient Characteristics for Electronically Prescribed Varenicline Characteristic Value Prescription erx varenicline prescriptions, No erx varenicline prescriptions with any pharmacy claim, 1472 (94.6) No. (%) Days supplied (intended), mean (SD) 28.1 (4.2) Quantity dispensed (intended), mean (SD) 54.5 (10.1) Patient No. of patients 1282 Male, No. (%) 644 (50.2) Age, y, mean (SD) 43.9 (11.7) Age categories, y, No. (%) a (3.1) (22.3) (25.4) (29.9) (16.0) >65 43 (3.4) erx indicates electronically prescribed. a Total does not add up to 100% due to rounding. Secondary Outcome Of the 1556 erx varenicline prescriptions, 84 prescriptions (57 patients) had no matching pharmacy claims. Only those with matching pharmacy claims (n = 1225) were included in the analysis for the secondary outcome (Figure). Demographic, prescription, and coverage characteristics were compared among prescriptions that were obtained and those that were not obtained (Table 2). Univariate analyses revealed statistically significant differences for age, initiation versus continuing therapy, and copayment. On average, patients who obtained varenicline were 2.9 years older than patients with did not obtain varenicline (P <.001). The majority of prescriptions that were obtained were for the starting month pack, while the majority of those that were unobtained were for continuing therapy (P <.001). The average copayment for prescriptions that were not obtained was $2.99 higher than the copayment for prescriptions that were obtained (P =.011). A post hoc analysis examined the percentage of prescriptions that were not obtained when copayments were categorized. For copayment ranges of $0.00 to $29.99, $30.00 to $44.99, and >$45.00, cohort members did not obtain 20.2%, 23.9%, and 27.8% of their prescriptions, respectively (P =.024). No significant differences were seen by sex and varenicline coverage. Statistically significant factors from univariate analyses were included in the logistic regression model (Table 3). The factors associated with failure to fill an electronic varenicline prescription were the same as those found in univariate analyses: age, initiation versus continuing therapy, and copayment. Prescriptions for younger patients (P <.001) and those with a higher copayment (P =.030) were less likely to be obtained. Prescriptions for continuing therapy were 2.23 times more likely to fail to be obtained than those for starting month pack (P <.001). DISCUSSION The US Public Health Service guideline recommends that insurance plans cover all smoking cessation medications, including varenicline, as they are highly cost-effective relative to other clinical interventions. 3 Similarly, one of the objectives of Healthy People 2020 was to have 100% coverage for smoking cessation products. 11 However, a large gap still exists between expert recommendations and coverage of smoking cessation products. As of 2009, there were still 8 states that did not provide any coverage for tobacco cessation medication for state employees, 12 while only 7 states had laws mandating some sort of smoking cessation coverage for all insurance plans. 13 A discussion with health plan stakeholders found that some health plans still believe that covering tobacco cessation medications will increase costs without producing commensurate healthcare savings, 14 despite strong evidence to the contrary. Our finding that more than one-fourth of smokers with pharmacy benefits did not obtain varenicline represents an opportunity to improve use of pharmacotherapy for smoking cessation. Insurance coverage for smoking cessation treatments increases treatment use and population quit rates. 6,15 In addition, providing access to these medications has been shown to be cost-effective. 3,6,15 States requiring smoking cessation treatment coverage for state employees had lower rates of absenteeism and lower utilization of healthcare resources Warner et al simulated the financial impact and cost-effectiveness of smoking cessation product coverage using data from a large MCO and the literature, and calculated that at 5 years, covering smoking cessation products costs the MCO $0.61 per member per month, while quitters gain an average of 7.1 life-years and the MCO incurs savings of $3417 for each life-year saved. 19 Besides providing coverage for smoking cessation products, health plans can also encourage utilization. Our study found that of those patients who did not obtain varenicline, 59% had approved coverage for the prescription. Further research would delineate the reasons for this overt e38 The American Journal of Pharmacy Benefits May/June 2011

5 Failure to Obtain Varenicline Table 2. Prescription and Patient Characteristics by Outcome (n = 1472) Characteristic Obtained erx Varenicline (n = 1112) Did Not Obtain erx Varenicline (n = 360) P Age, y Mean (SD) 43.7 (11.7) 40.8 (11.6).001 Sex Male, No. (%) 567 (51.0) 178 (49.4).610 Female, No. (%) 545 (49.0) 182 (50.6) Varenicline coverage, No. (%) Coverage 923 (83.0) 298 (82.8).921 No coverage 189 (17.0) 62 (17.2) Initiation vs continuing therapy, No. (%) Starting month pack 747 (67.2) 173 (48.1).001 Continuing therapy 365 (32.8) 187 (51.9) Copayment, $ Mean ± SD (range) ± ( ) ± ( ).011 erx indicates electronically prescribed. nonadherence, which might include lack of awareness of coverage or the cost of the product. A survey of smokers with pharmacy benefits found that only 30% were aware that their health plan covered smoking cessation treatments, and those patients who were less aware were less likely to use pharmacologic treatment. 20 The use of electronic prescribing offers a way to improve use of smoking cessation therapies. A recent ruling by the Centers for Medicare & Medicaid Services requires electronic prescribing systems to have the capability of providing formulary and benefit transaction, medication history transaction, and fill status notification to prescribers. 21 Prescribers can readily access patients insurance coverage information. Formulary decision support, as part of an electronic prescribing system, has been shown to increase utilization of formulary products. 22 Provider follow-up can also improve the use of smoking cessation pharmacotherapies. Fill status notification allows bidirectional communication between the prescriber and pharmacy so that prescribers can be aware that their patient failed to fill their varenicline prescription. Providers who are notified that their patients failed to fill can contact them to encourage use. Higher copayment was associated with failure to obtain varenicline. In a comparison of different levels of coverage for smoking cessation medications within a large HMO over 2 years, Curry et al found that the use of smoking cessation services (behavioral program plus nicotine replacement therapy) was greater with full prescription coverage than with a 50% costsharing plan (5.3% vs 4.2%, respectively). 23 The percentage of patients using a behavioral program along with nicotine replacement therapy was 10% higher among those with full prescription coverage than among those required to pay 50% of the cost of the nicotine replacement therapy (P =.0004). Similarly, the Cochrane Collaboration concluded that providing full coverage of smoking cessation products can increase self-reported abstinence rates at relatively low cost when compared with partial or no benefits. 15 Our results show that younger patients were at higher risk for failure to obtain varenicline. This is especially important from a public health perspective as we know that younger adults are more likely to be current smokers than older adults 24 and represent a group that should be targeted for intervention. Furthermore, younger smokers were more likely than older smokers to report a quit attempt, despite higher rates of smoking. 25 One study found that young adults aged 18 to 24 years were more likely to succeed in quitting than smokers aged 35 to 64 years. 26 Most importantly, people who quit smoking before age 35 have a life expectancy similar to those who have never smoked. 27 We also found that prescriptions for continuing therapy were more likely to be unobtained. This may be due to therapy failure or to plan quantity limitations used by self-insured groups. For example, certain self-insured groups only allow 1 cycle of therapy for the lifetime of the benefit, while others allow a 90-day supply per year. It should be noted by self-insured groups that most smokers who attempt to quit but relapse want to quit again right away 28 and preventing smokers from making repeated attempts to quit is not cost-effective. Vol. 3, No. 3 The American Journal of Pharmacy Benefits e39

6 n Cooke Glover Xing Lee Table 3. Logistic Regression Analysis: Predictors of Failure to Obtain Electronically Prescribed Varenicline (n = 1472) a Characteristic Odds Ratio (95% CI), With Reference Category = 1 P Mean age 0.98 (0.97, 0.99).001 Initiation vs continuing therapy Starting month pack 1 Continuing therapy 2.23 (1.75, 2.85).001 Mean copayment 1.01 (1.00, 1.01).030 CI indicates confidence interval. a Log-likelihood value = Test that all slopes are zero: G = , df = 3, P <.001. Merely providing coverage for smoking cessation pharmacotherapy may not be enough. A Minnesota study involving 2 health plans studied abstinence rates when coverage was expanded to include smoking cessation products. 20 Researchers found that merely adding the benefit had no effect on medication utilization or abstinence rates after 1 year. However, smokers who were aware that their benefit covered smoking cessation products had much higher use of these products. Some states have tried expanding health insurance coverage for tobacco treatments by making it mandatory. For example, the state of Maryland, where this member cohort mainly resides, requires health insurance companies to provide at least two 90-day sessions per year of coverage for all prescription drugs approved by the Food and Drug Administration for tobacco dependence treatment, including varenicline. 29 However, this requirement only applies to fully insured groups where the health insurance company takes on risk. For self-insured groups where the health plan only acts as the benefit administrator, health plans need to educate groups regarding the benefits of covering smoking cessation therapies. This was a retrospective study that examined electronic and claims data, and as such, it was subject to several limitations. Electronic prescribing is not widely incorporated into clinical practice, although its use is increasing. Only 12% of office-based US physicians were electronically prescribing by the end of 2008, 30 and smokers who are cared for by providers using electronic prescribing may be different from the general population of smokers. Another limitation is that 84 electronic prescriptions had no matching pharmacy claims. This situation would have occurred when pharmacies either had no available patient insurance information or processed the prescription as a cash prescription. Patients paying cash or choosing not to access their pharmacy benefits would not have any paid pharmacy claims and would have been mislabeled as having failed to obtain varenicline. In addition, these 84 electronic prescriptions could not be included in the secondary outcome analysis due to lack of claim information on copayment. Another important consideration is that patients who are in possession of medication may not always take the medication, so evaluating first-fill rates only serves as a proxy to adherence. Lastly, we only examined patients who obtained varenicline within 45 days of the erx varenicline date, so these results do not imply anything about persistence or duration of therapy. CONCLUSION More than one-fourth of patients from this mid-atlantic MCO failed to obtain varenicline due to access barriers and overt nonadherence. Younger patients were at higher risk for failure to obtain varenicline. Prescriptions for continuing therapy and those with higher copayments also were less likely to be filled. Lack of access to varenicline, an important therapy to assist in smoking cessation, increases the risk for therapeutic failure or relapse. Unintended consequences include an increase in the risk for smokingrelated illness and an added economic burden of therapy failure. Strategies to improve utilization of smoking cessation products (eg, follow-up from healthcare providers and payers, improved formulary coverage, increased awareness of coverage) should be used. Future research should examine cost-efficient interventions to improve the uptake of smoking cessation therapies. Author Affiliations: From PosiHealth, Inc (CEC), Ellicott City, MD; University of Maryland School of Pharmacy (CEC, SX), Baltimore, MD; Department of Public and Community Health (EDG), Center for Health Behavior Research, University of Maryland School of Public Health, College Park, MD; and CareFirst BlueCross BlueShield (HYL), Baltimore, MD. Funding Source: Support for this research was provided by an Investigator Initiated Research Grant from Pfizer Inc. Author Disclosures: Dr Cooke reports serving as a consultant for Eli Lilly and Company and Novartis, receiving grants from Bristol-Myers Squibb, Novartis, Novo Nordisk, and Pfizer Inc, and owning stock in Pfizer Inc. The other authors (EDG, SX, HYL) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Authorship Information: Concept and design (CEC, EDG, SX, HYL); acquisition of data (EDG, HYL); analysis and interpretation of data (CEC, EDG, SX, HYL); drafting of the manuscript (CEC, EDG, SX); critical revision of the manuscript for important intellectual content (CEC, EDG, SX); statistical analysis (CEC); provision of study materials or patients (EDG); obtaining funding (EDG); administrative, technical, or logistic support (EDG); and supervision (EDG). Address correspondence to: Catherine E. Cooke, PharmD, BCPS, PAHM, President, PosiHealth, Inc, 5106 Bonnie Branch Road, Ellicott City, MD ccooke@posihealth.com. e40 The American Journal of Pharmacy Benefits May/June 2011

7 Failure to Obtain Varenicline REFERENCES 1. Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults and trends in smoking cessation United States, MMWR Morb Mortal Wkly Rep. 2009;58(44): US Department of Health and Human Services Surgeon General s report the health consequences of smoking. data_statistics/sgr/2004/index.htm. 3. US Department of Health and Human Services. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004;99(1): Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation [update in: Cochrane Database Syst Rev. 2010;12:CD006103]. Cochrane Database Syst Rev. 2008;(3):CD Cokkinides VE, Ward E, Jemal A, Thun MJ. Under-use of smoking-cessation treatments: results from the National Health Interview Survey, Am J Prev Med. 2005;28(1): Shaw JP, Ferry DG, Pethica D, Brenner D, Tucker IG. Usage patterns of transdermal nicotine when purchased as a non-prescription medicine from pharmacies. Tob Control. 1998;7(2): Burns ME, Rosenberg MA, Fiore MC. Use and employer costs of a pharmacotherapy smoking-cessation treatment benefit. Am J Prev Med. 2007;32(2): Burns ME, Fiore MC. Under-use of tobacco dependence treatment among Wisconsin s fee-for-service Medicaid recipients. WMJ. 2001;100(3): ehealth Initiative and Center for Improving Medication Management. A clinician s guide to electronic prescribing. White Paper from the ehealth Initiative and The Center for Improving Medication Management. electronic-prescribing-resources.html. Published Healthy People 2020 Summary of Objectives: tobacco use. people.gov/2020/topicsobjectives2020/pdfs/tobaccouse.pdf. Accessed May 25, American Lung Association. State Employee Health Plans Should Cover Cessation Treatments American Lung Association. All Insurance Plans Should Cover Tobacco Cessation Treatments Gollust SE, Schroeder SA, Warner KE. Helping smokers quit: understanding the barriers to utilization of smoking cessation services. Milbank Q. 2008;86(4): Kaper J, Wagena EJ, Severens JL, Van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment [update in: Cochrane Database Syst Rev. 2009;(2):CD004305]. Cochrane Database Syst Rev. 2005;(1):CD Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benefit among employed populations. J Occup Environ Med. 2007;49(1): Harris JR, Schauffler HH, Milstein A, Powers P, Hopkins DP. Expanding health insurance coverage for smoking cessation treatments: experience of the Pacific Business Group on Health. Am J Health Promot. 2001;15(5): Sindelar JL, Duchovny N, Falba TA, Busch SH. If smoking increases absences, does quitting reduce them? Tob Control. 2005;14(2): Warner KE, Mendez D, Smith DG. The financial implications of coverage of smoking cessation treatment by managed care organizations. Inquiry. 2004;41(1): Boyle RG, Solberg LI, Magnan S, Davidson G, Alesci NL. Does insurance coverage for drug therapy affect smoking cessation? Health Aff (Millwood). 2002;21(6): Centers for Medicare and Medicaid Services. E-prescribing: adopted Part D e-prescribing standards. Standard%20and%20Transactions.asp. 22. Fischer MA, Vogeli C, Stedman M, Ferris T, Brookhart MA, Weissman JS. Effect of electronic prescribing with formulary decision support on medication use and cost. Arch Intern Med. 2008;168(22): Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. New Engl J Med. 1998;339(10): Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics. Figure 2: Prevalence of current smoking among adults aged 18 years and over, by age group and sex: United States, In: A Program for Early Release of Selected Estimates From the National Health Interview Survey. ER_booklet.pdf. Published Solberg LI, Boyle RG, McCarty M, Asche SE, Thoele MJ. Young adult smokers: are they different? Am J Manag Care. 2007;13(11): Messer K, Trinidad DR, Al-Delaimy WK, Pierce JP. Smoking cessation rates in the United States: a comparison of young adult and older smokers. Am J Public Health. 2008;98(2): Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years observations on male British doctors. BMJ. 2004;328(7455): Fu SS, Partin MR, Snyder A, et al. Promoting repeat tobacco dependence treatment: are relapsed smokers interested? Am J Manag Care. 2006;12(4): Maryland Insurance Surescripts National Progress Report on e-prescribing, Plus What s Ahead in 2010 and Beyond. Vol. 3, No. 3 The American Journal of Pharmacy Benefits e41