APPENDIX B

Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey

AMCP MANAGED CARE FORMULARY AND PHARMACY BENEFIT DESIGN SURVEY (JANUARY 2000)

Plan/Company name: ___ (for in-house use only)

Please list the total number of covered/managed lives serviced. ___

The P&T Committee

What is the composition (number of members) of your P&T committee:

  1. Pharmacists ___

  2. Physicians ___

  3. Other Healthcare Professionals ___

Exclusion of Coverage

Regardless of the existence of a formulary or a system of nonformulary prior authorizations for exceptions, how many covered lives are enrolled in plans that exclude the following drug classes for reimbursement as a benefit design restriction:

DESI drugs? ___

Experimental drugs ___

Off-label use? ___

OTC? ___

Cosmetic drugs or life-style drugs? ___

Survey sent by the Academy of Managed Care Pharmacists to eight members covering 200 million lives in the United States.



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OCR for page 227
DESCRIPTION AND ANALYSIS OF THE VA National Formulary APPENDIX B Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey AMCP MANAGED CARE FORMULARY AND PHARMACY BENEFIT DESIGN SURVEY (JANUARY 2000) Plan/Company name: ___ (for in-house use only) Please list the total number of covered/managed lives serviced. ___ The P&T Committee What is the composition (number of members) of your P&T committee: Pharmacists ___ Physicians ___ Other Healthcare Professionals ___ Exclusion of Coverage Regardless of the existence of a formulary or a system of nonformulary prior authorizations for exceptions, how many covered lives are enrolled in plans that exclude the following drug classes for reimbursement as a benefit design restriction: DESI drugs? ___ Experimental drugs ___ Off-label use? ___ OTC? ___ Cosmetic drugs or life-style drugs? ___ Survey sent by the Academy of Managed Care Pharmacists to eight members covering 200 million lives in the United States.

OCR for page 227
DESCRIPTION AND ANALYSIS OF THE VA National Formulary Other? (please specify the drug class) ___ How many covered lives are in plans with: 1–2 excluded classes? ___ 3–5 excluded classes? ___ >5 excluded classes? ___ Closed Formularies How many covered lives are in plans that have a pharmacy benefit with a closed or partially closed formulary; that is, a formulary that limits and requires justification for use of drugs not listed on the formulary independent of those drugs excluded through benefit design? ___ How many covered lives are in plans with: (See top of page 2 for definition) 1–2 closed classes? ___ 3–5 closed classes? ___ >5 closed classes? ___ (That is, classes in which some drugs are not listed on the formulary, are not covered or reimbursed, and can be obtained only through a nonformulary exceptions process.) How many covered lives are in plans with closed classes that contain only one drug? ___ What are the closed classes in your plans? ___ ___ ___ Which processes are in place in closed formulary environments to allow for access to nonformulary drugs? (check all that apply) None, all nonformulary drugs are not covered. ___ Nonformulary drugs may be covered through an informal exceptions process. ___ Nonformulary drugs may be covered through a formal prior authorization process. ___ Other, describe. ___ Open–Preferred Formularies How many covered lives are in plans that have nonclosed formularies but have preferred classes, that is, classes in which there are drugs whose use is encouraged by incentives (lower copay, academic detailing, DUR, soft edits), or usage criteria, or in which prescribing of nonpreferred drugs is discouraged. ___

OCR for page 227
DESCRIPTION AND ANALYSIS OF THE VA National Formulary How many covered lives are in plans with: 1–2 preferred classes? ___ 3–5 preferred classes? ___ >5 preferred classes? ___ What are the preferred classes in your plans? ___ Open–Passive Formularies How many covered lives are in plans where an open formulary is used but the items listed are only passively promoted (use of educational materials, few soft edits)? ___ Other Types of Formularies How many covered lives are in plans: that have no formulary, but selected drugs are labeled as “Require Prior Authorization?” ___ that have no formulary or prior authorization process, but pharmacists perform DUR and physicians are notified when inappropriate use is identified? ___ that have no formulary, no controls, or no checks on physician practice patterns. All drugs go through as covered and access is open? ___ Drug Restrictions How many covered lives are in plans that restrict coverage or reimbursement of specific drugs or classes of drugs to specific prescribers, settings, or disease conditions? ___ Generic Drugs How many covered lives are in plans that require generic substitution? ___ Access to Nonformulary Drugs How many covered lives fall under formulary systems which: Have a nonformulary exceptions process for coverage? ___ Use copay design controls to influence use of nonformulary drugs? ___ Cost-Containment Measures How many covered lives fall under plans whose system edits include: Limits on numbers of prescriptions per patient at any time or per unit time?

OCR for page 227
DESCRIPTION AND ANALYSIS OF THE VA National Formulary Limits on refills of prescriptions (number of drugs with such limits)? ___ Limits on duration of use of some drugs (number of drugs with such limits)? ___ Limits on the supply of drugs per prescription or on hand? ___ Presence of a prior approval process for some drugs (number of drugs requiring prior approval)? ___ Addition of New FDA-Approved Drugs How many covered lives are in plans that limit formulary addition of new FDA-approved drugs by requiring waiting periods? ___ How many covered lives are in plans that require waiting periods of more than 6 months? ___ Do any enrollees participate in plans that have policies in place to actively review or monitor activities at the FDA such that reviews of new drugs are done concurrently (proactively) with FDA approval? Yes ___ No ___ If yes, the number of covered lives in plans that proactively review/monitor for new AIDS/cancer medications. ___ If yes, the number of covered lives in plans that proactively review/monitor for new FDA “1P” drugs. ___ If yes, the number of covered lives in plans that proactively review/monitor for new FDA “standard” designation drugs. ___ Appeals Process How many covered lives are in plans that: have an internal appeals process for denials of drug coverage or reimbursement for excluded drugs? ___ have an internal appeals process for denials of nonformulary drug requests? ___ have an appeals process subject to independent external review? ___ Continuation of Care How many covered lives are in plans that provide continuation of coverage after removal of a drug from the formulary? (Choose which one applies) Policy applies to a few specific drugs. ___ How many covered lives? ___ Policy applies to all drugs. ___ How many covered lives? ___ Are there financial penalties incurred by patients? (Please describe) ___ ___