Aetna Pharmacy Management Systematic Reviews of Comparative Effectiveness Payor View Edmund Pezalla, MD, MPH Chief Clinical Officer Aetna Pharmacy Management

2 Use of Medical Evidence in the payor context 1.Coverage determination 2.Provider payment policy 3.Determination of quality of care 4.Prediction of practice patterns 5.Guidance for members and providers

Aetna Pharmacy Management 3 Coverage determination Request for procedure Application of clinical policy Denied: experimental Covered with evidence development Covered UM Copay level

Aetna Pharmacy Management 4 Coverage for pharmaceuticals Medical evidence Copay tier Step therapy Prior authorization Formulary Benefit design Out-of-pocket expenses

Aetna Pharmacy Management 5 Data sources  Published trials  Published reviews  National guidelines  Drug compendia  FDA/regulatory data and labels  Internal data  Unpublished results by mfr and academic centers Currently used

Aetna Pharmacy Management 6 Issues  Data developed for other purposes may not answer all of the questions  Small trial size, especially for surgical procedures  Lack of information to help control for confounders  Lack of active comparators in many trials

Aetna Pharmacy Management 7 Data grading  Current systems promote RCT over all other types of studies  There is no accepted scale for ranking non-randomized or retrospective studies  Methods for combing types of studies are limited

Aetna Pharmacy Management 8 Payors and grading of evidence  Standardized approaches can: – Increase acceptance – Improve decision making – Encourage research and publications – Allow for use of internal data or increase publication of analysis of that data by payors

Aetna Pharmacy Management 9 Thank You Ed Pezalla Aetna