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Description and Analysis of the VA National Formulary (2000)

Chapter: Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey

« Previous: Appendix A: Interim Report of the Committee on VA Pharmacy Formulary Analysis to the Department of Veterans Affairs and the Congress of the United States
Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
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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.

Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

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. ___

Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

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?

Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

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
  1. 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? ___

  2. Are there financial penalties incurred by patients? (Please describe)

    ___

    ___

Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
Page 227
Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
Page 228
Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
Page 229
Suggested Citation:"Appendix B: Academy of Managed Care Pharmacy's Managed Care Formulary and Pharmacy Benefit Design Survey." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
Page 230
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The VA National Formulary generated controversy, which motivated congressional scrutiny and a directive to the VA to commission this report reviewing the experience with the National Formulary and formulary system. This Institute of Medicine committee was pleased to assist the Congress with this review, in part because the committee saw in the VHA example an opportunity to understand and anticipate problems that all publicly funded programs are likely to encounter in this new age of pharmaceuticals. The Congress asked the committee to review the restrictiveness of the National Formulary, its impact on the costs and quality of care in the VHA, and how it compared to formularies and drug management practices in the private sector and in other public programs, especially Medicaid. Detailed in the pages that follow, the committee's findings and conclusions on these questions are, the committee believes, highly instructive, though not always in the ways that we anticipated.

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