Other? (please specify the drug class) ___

How many covered lives are in plans with:

  1. 1–2 excluded classes? ___

  2. 3–5 excluded classes? ___

  3. >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. ___



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