OBJECTIVES : A better understanding of formulary management issues, reviews/coverage and changes.

METHODS : Online survey of senior officers from health plans, insurers, and PBMs. Changes (>2%) from prior surveys reported.

RESULTS : Survey completed by 85 respondents from health plans,IDNs,ACOs,PPOs, and SPs. Respondents served on a variety of committees. Advisors/plans covered multiple member types: Commercial FFS=41%, Medicaid=70%, IDN=57%, HMO/PPO=22%, Employer self-funded=22%. Accountable care/disease management programs included primary care,Hepatitis-C,Lipid management,diabetes, and joint replacement. Plans cover rare diseases restricting use thru PAs=54.7%, based on: risk/benefits=20.3%, safety&efficacy=18.8%;contracting=3.1%,cost=1.6%,# of members with the condition=1.6%. Clinician-administered agents were always under the medical-benefit (37.7%↓6.3%), 2.9% exclusive under the pharmacy-benefit, 46%↓8.2% was mixed, 5.8%↓4.4% plan-design mandated. Changes were not anticipated by 57%↓15.9% of respondents. SP product member co-pays for fixed vs. percent with minimal changes with 36% using co-pay accumulator programs (36%). Approximately 65% of oral biologics and self-injected products were covered under the pharmacy-benefit, with no benefit changes anticipated (68%). Based on therapy cost, on-going monthly=43.5%, annual=30.5%, and “one-and-done” (26%) treatments were preferred. Respondents involved in decisions for prescription drugs (all 64%,some 27%) and medical-devices (all 33%,some 50%), and only 65% require submission of AMCP-dossiers for prescription products (all 34%,some 28%). Budget impact models (BIMs) were used in 77%↓11% of pharmaceutical products, and in 63%↑18% of devices. Most BIMs were developed internally=38%, others with manufacturers. 86% indicated they would cover preventative medications for conditions. Rebate disclosures were supported from pharmaceutical manufacturers=60%, health plans=59%, and through total cost publications=61%.

CONCLUSIONS : The managed care P&T Committee decision-making process is undergoing a series of changes and will continue to establish standards for therapeutics and continue to ensure high quality drug therapy for its members in a cost-effective manner. Medical+pharmacy directors have distinct opinions as to how to alter the process to adapt to influences and cover new therapies with different administration schedules and for rare disorders.