Avalere Health LLC | The intersection of business strategy and public policy Formulary Design: Balancing Cost and Access November 1, 2005 Presented By:

Slides:

Advertisements

Similar presentations

Understanding Private Payers & Maximizing Private Payer Reimbursement Strategies: Understanding the Process Barbara Grenell, Preferred Health Strategies.

Advertisements

1 Medicare Part D: Cost Management Issues Jack Hoadley Research Professor Georgetown University Health Policy Institute Families USA Health Action 2005.

1 Help! I Couldnt Get My Prescription Filled: Whats Going On and What Can I Do About It? Health Action 2006 Health Assistance Partnership January 28, 2006.

What You Wanted to Know About Formularies Emmanuelle Mirsakov Pharm.D. Candidate 2007 USC School Of Pharmacy.

Management of Drug Formulary Dimitry Gotlinsky Western University Managed Care Clerkship ProPharma Pharmaceutical Consultants, Inc. 06/16/06.

Medication Management

Commonwealth Connector Minimum Pharmacy Standards October 11, 2007.

Module 3: TRICARE Options. 2 Module Objectives After this module, you should be able to: Describe some of the key features of the TRICARE Standard, Extra,

Update on Process Recommendations to the Executive Committee, Governor, and Exchange Board Next two sessions: options for analysis Goals/criteria Options.

Connecticut Department of Social Services Health Care Contracting Opportunities Charter Oak – HUSKY A – HUSKY B Bidders’ Conference February 22, 2008 M.

Value & Coverage Issue Brief Slides A Closer Look at Health Plan Coverage Policies and Approaches.

State Specific Example: Texas The intersection of business strategy and public policy.

Meredith Cook Mercer COPHS August, Beers Criteria AGS and interdisciplinary panel of 11 experts in geriatrics and pharmacotherapy 53 medications.

Medicare Annual Enrollment Important Medicare Updates for 2015.

Deciphering Medicare Part D Susan Miller, Patient Education Douglas A. Magenheim, MD, MBA, FACP.

CITY OF LAREDO HUMAN RESOURCES DEPARTMENT By: Daniel E. Migura Jr. HEALTH & BENEFITS FUND.

Long Term Care: Medicare Prescription Drug Coverage in Institutions and Our Communities Larry Kocot Vanessa Duran.

© 2005 National Mental Health Association The Medicare Drug Benefit: What Is It and What Does it Mean for Mental Health? Get Educated, Get Enrolled An.

TAYLOR MELANSON Providing Prescription Drug Coverage to the Elderly: America’s Experiment with Medicare Part D By Mark Duggan, Patrick Healy, and Fiona.

Medicare Part D Overview of Options, Creditable Coverage, Required Notices, COB and Health Care Reform.

Medicare Modernization Act, Part D Prescription Drug Benefit Presentation for County Program Administrators September 1, 2005.

Special Needs Plans Susan Nedza, M.D., M.B.A. Chief Medical Officer, CMS Chicago Regional Office March 23, 2006.

Joint Informational Hearing The Federal Medicare Prescription Drug Act: State Readiness, Implementation, and Consumer Issues Bonnie Burns, Training and.

Welcome to Medicare Prescription Drug Coverage Discussion Topics  What is Medicare?  What is the Medicare Prescription Drug Plan benefit?  Can I also.

© 2005 National Mental Health Association The Medicare Drug Benefit: What Is It and What Does it Mean for Mental Health?

“Reaching across Arizona to provide comprehensive quality health care for those in need” Our first care is your health care Arizona Health Care Cost Containment.

Your Medicare Prescription Drug Coverage Module 9A.

Transitions: Moving Dual Eligibles to Medicare Prescription Drug Coverage Tony Culotta, Director, Appeals and Enrollment Group Babette Edgar, Director,

1 Variation in Medicare Part D Prescription Drug Plan Benefits, 2006 Leslie M. Greenwald, Ph.D. Principal Scientist RTI, International.

1 Governor’s Office of Health Policy and Finance MaineCare Pharmacy Initiatives.

Avalere Health LLC | The intersection of business strategy and public policy The Potential Impact of the New Prescription Drug Benefit on Medicare Beneficiaries.

1 Medicare Part D: Cost Management Issues Jack Hoadley Research Professor Georgetown University Health Policy Institute National Academy of Social Insurance.

The Changing Reimbursement System: Interaction Between Medicare Part B and Medicare Part D The intersection of business strategy and public policy.

Retiree Health Benefits Program Medicare Part D and Your State Benefits Your Benefits Choices.

1 Iowa Medicaid Preferred Drug List Presented by: Timothy Clifford, MD September 28 & 29, 2004.

Avalere Health LLC | The intersection of business strategy and public policy The Medicare Modernization Act: The Impact on States and Low-Income Beneficiaries.

Medicaid Fee-for-Service: Prior Authorization Criteria & the Role of the DUR Board Charles Agte, Pharmacy Administrator Health Care Services June 19, 2013.

Avalere Health LLC | The intersection of business strategy and public policy Medicare Prescription Drug Payment Presented by Margaret Nowak September 24,

Medicare Advantage Quality Measurement & Performance Assessment Conference April 8, 2008 Medicare Part D Reporting Requirements Alice Lee-Martin, PharmD.

Improving Value in Health Care: Challenges and Potential Strategies Arnold M Epstein October 24, 2008 Congressional Health Care Reform Education Project.

1 State Options for Supplementing Medicare Part D Drug Coverage Invitational Summit on Medicare Part D Implementation Issues Jack Hoadley Georgetown University.

MEDICATION MANAGEMENT P&T COMMITTEE AND FORMULARY MANAGEMENT EMTENAN ALHARBI, Msc CLINICAL PHARMACIST.

Overview of the New Medicare-Endorsed Prescription Drug Discount Card Program The Intersection of Business Strategy and Public Policy The Health Strategies.

Avalere Health LLC | The intersection of business strategy and public policy Part D Plans and Specialty Products Presented by Lovisa Gustafsson.

Special Needs Plans Sandra Bastinelli, MS, RN Acting Director, Division of Special Programs Medicare Advantage Group Center for Beneficiary Choices.

Avalere Health LLC | The intersection of business strategy and public policy Enrollment in the Medicare Drug Benefit Medicare Congress Audioconference.

Avalere Health LLC | The intersection of business strategy and public policy The Impact of Enrollment in the Medicare Prescription Drug Benefit on Premiums.

Overview of the New Medicare-Endorsed Prescription Drug Discount Card Program The Intersection of Business Strategy and Public Policy The Health Strategies.

Drug Formulary Development & Management

Technology, Information Systems and Reporting in Pharmacy Benefit Management Presentation Developed for the Academy of Managed Care Pharmacy Updated: February.

Pharmacist Opportunities Within a Pharmacy Benefit Manager Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2015.

Pharmacy Benefit Design Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2016.

Formulary Manufacturer Contracting Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2015.

Special Needs Plans (SNP) Overview of SNP Assessment and S&P Measures June 2010.

Managed Care Models: The Benefit vs. Cost Balance

Promoting consumer access to affordable Prescription drugs

Medicaid Coverage of Pharmaceuticals Life Science Tennessee

Pharmacy & Therapeutics Committee

Medicare and Medicaid Week 3.

Clinical Leadership Decision Process

Pharmacy & Therapeutics Committee

Navigating the Health Insurance Marketplace

Lindy Hinman Avalere Health LLC

Primum non nocere Olabisi Oshikanlu M.D., F.A.A.P

Third National Medicare Congress

Jan Berger, M.D., M.J. Senior Vice President Chief Medical Officer

Pharmacy & Therapeutics Committee

Presented by Tricia Neuman, Sc.D.

Medicare Advantage 101: A Primer

Pharmacy & Therapeutics Committee

Presentation transcript:

Avalere Health LLC | The intersection of business strategy and public policy Formulary Design: Balancing Cost and Access November 1, 2005 Presented By: Margaret Nowak Avalere Health LLC

© Avalere Health LLC Page 2 Agenda The Evolution of Part D Plan Formularies »Classification systems »CMS review criteria »Timing of formulary changes »B vs. D

© Avalere Health LLC Page 3 Plans’ Formularies Must Meet CMS Guidelines  Plans must provide choices of medications »Must include at least two drugs in each category that are not therapeutically equivalent and bioequivalent  CMS must determine that a plan’s categorization scheme is not discriminatory against certain types of patients  Plans will resubmit formularies and bids for approval by CMS every year

© Avalere Health LLC Page 4 Potential Plan Benefit Management Tools  Formulary Management: »Prior Authorization »Step Therapy »Tier Placement »Generic Substitution »Therapeutic Equivalent Substitution  Clinical Programs  Cost Sharing  Mail Service vs. Retail

© Avalere Health LLC Page 5 Formularies Can Be Changed During the Plan Year  Formularies can be updated at certain times throughout the year »Medicare P&T committees will meet quarterly to consider changes to the plan’s drug list »Therapeutic categories will be reviewed annually »Formularies cannot be changed between November 15 and March 1 of each year (during open enrollment period + 60 days after)  CMS must approve all formulary changes – Plans must submit changes between the 1st day and the 7th day of each month (beginning November 2005); CMS will review within 30 days

© Avalere Health LLC Page 6 How Will Part D Plans Look At Formulary Development?  Decision hierarchy: »What category or class does drug fall? Competitors? »Does drug have specific indications that are relevant to the population? – May use disease management, prior authorization to manage drugs for certain indications »Does drug have special use considerations (e.g., therapy after generic drug has failed) – May use step therapy, specify only certain dosages/quantity  Decision drivers »Evidence of care »Costs »Population base

© Avalere Health LLC Page 7 The Future: Product Positioning  What happens if a drug with multiple competitors in a category or class does not make it on formulary? »Demonstrate cost effectiveness – In and among the elderly/disabled patient population »Demonstrate superior clinical outcomes – In and among the elderly/disabled patient population »Request additional tiers or placement via benefit management tools (e.g., step therapy advantage)

© Avalere Health LLC Page 8 Medicare Part D and the Benefit Design Options 1. Standard Rx Drug Coverage »Minimum benefit design defined by law to be acceptable for providing Part D Rx drug coverage »Basis for comparison across plans offered by different sponsors 2. Alternative Rx Drug Coverage ( basic or enhanced ) »Must be at least actuarially equivalent to the standard benefit »Actuarial tests and options for plan configuration vary for different benefit design alternatives

© Avalere Health LLC Page 9 Key Questions What do we know about plan offerings today?  Formulary and Benefit Design What should we anticipate on January 1, 2006 and beyond?