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:
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Pharmacists ___
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Physicians ___
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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. |
Other? (please specify the drug class) ___
How many covered lives are in plans with:
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1–2 excluded classes? ___
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3–5 excluded classes? ___
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>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. ___
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?
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
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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? ___
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Are there financial penalties incurred by patients? (Please describe)
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