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

2. 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

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

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

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trials  Published reviews  National guidelines  Drug compendia  FDA/regulatory data and labels  Internal data  Unpublished results by mfr and academic centers Currently used

6. 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

7. 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

8. 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

9. Aetna Pharmacy Management 9 Thank You Ed Pezalla Aetna pezallae@aetna.com