Once a drug formula has been selected, a formula management solution is required to ensure that drugs paid for by the employer and members have the highest clinical value at the lowest possible net cost. This first involves reviewing the list of drugs to ensure that it covers only the most clinically and cost-effective drugs and reduces exposure to less clinically significant and less expensive drugs. Formula optimization means taking additional steps to maximize the value of the formula collection for the plan. We examined the 57 unique drug formulas available in the 750 Medicare Part D drug plans in November 20162 to determine how often brand-name products received a cheaper formula placement than generics. We defined favorable placement as the placement of a branded product in a lower level of cost-sharing or where a branded product had fewer usage controls (i.e., pre-approval, step-by-step therapy, or quantity restrictions) than the corresponding generic. We analysed drugs for which generics and brand-name products were available3 (hereinafter referred to as multi-source drugs) and examined the lowest concentration per drug when multiple concentrations were available. We compared drug prices by dividing the average unit cost of branded products by the average unit cost of corresponding generics in 2016. Medicare Part D claims data.4 Due to the confidentiality of price concessions, this approach may have overestimated the price difference between brands and generics. The Johns Hopkins Institutional Review Board`s research policy for human participants noted that this study did not require approval because it did not include research for human participants.

In cases where a particular unformulated or non-preferred drug is the clinically appropriate drug for a person, drug performance plans have an appeal mechanism. Patients whose calls are successful may receive benefits for the non-preferred product as if it had a preferred status on the formula. A medication formula is a list of prescription drugs preferred by your health care plan. If you have private insurance or government coverage for your prescriptions, you can save time and money by familiarizing yourself with your payer`s medication formula. A formula consists of prescription drugs and usually includes generics and brand-name drugs. The sample consists of 222 multi-source drugs included in all Medicare Part D formulas for prescription drugs where the brand name drug and generic drug were included in at least 1 formula. PBMs will use a variety of techniques to promote the use of preferred formula drugs. The most effective tool for ensuring adherence to formulas is the performance structure or plan design, where preferred drugs have a lower cost share of members. Drug formulas are a complex part of the equation for pharmacy service management.

PBMs often update their formulas by adding newly approved drugs, adding/removing existing drugs based on PBM manufacturer contracts, and evaluating animal placement for the drugs contained. Choosing the most appropriate formula for each of your self-funded employer clients is an important part of ensuring that their prescription drug program is in place for optimal clinical and economic outcomes. We also looked at 222 multi-source drugs that were covered by all formulas and whose brand and generic products were covered by at least 1 formula. In total, 11 of these drugs (5.0%) had brand-name products that were more often classified at a lower cost-sharing level than the corresponding generics, and 67 drugs (30.2%) had brand-name products used less frequently than generics (Figure). While this report is designed to address the systemic barriers to drug formula that patients with behavioral problems face, many lessons are also applicable to patients with other health conditions. Results: In 67 insurance plans and 12 insurance plans, drugs were classified as a preferred investment in 59.1% of cases. The preferred investment index ranged from 31.3% to 88.1% in plans for the entire sample of 67 drugs; For the cardiovascular drug sample, the range was 25.0% to 100.0%. The results were robust in all sensitivity analyses. Some plans require patients to pay the full cost of their prescribed medications until they reach their deductible, and only after that to burden patients with formula-based co-payments.

Plans may also use a co-insurance system where the patient pays a percentage of drug costs, rather than a fixed co-payment amount. Healthcare professionals perform many functions in the formula management process. Pharmacists often lead infant formula management initiatives, coordinate the roles of P&T committees, and make recommendations based on sound clinical evidence. To ensure the success of the formula management process, pharmacists guide P&T committees through the drug selection process. Pharmacists also develop performance-related policies, treatment guidelines and use management strategies. Pharmacists and physicians also sit as voting members of P&T committees. As we discussed in Part 1 of this series on drug formula management, it is important to understand what a drug formula is and how a drug formula works. There are separate review and approval processes that govern how prescription drugs are approved and added to the PBM formula.

The U.S. Food and Drug Administration`s (FDA) review process has always considered the clinical effectiveness of the drug, while decisions regarding formula placement, pricing, and manufacturer discounts are handled by the PBM after a drug is approved by the FDA. When helping your clients choose a drug formula and optimal formula management solutions, it is important to consider access to medications and the cost to the plan and its members, as well as how the contractual terms related to drug discounts align with these decisions. .