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Formulary Design: Balancing Cost and Access November 1, 2005

Formulary Design: Balancing Cost and Access November 1, 2005. Presented By: Margaret Nowak Avalere Health LLC. Agenda. The Evolution of Part D Plan Formularies Classification systems CMS review criteria Timing of formulary changes B vs. D. Plans’ Formularies Must Meet CMS Guidelines.

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Formulary Design: Balancing Cost and Access November 1, 2005

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  1. Formulary Design: Balancing Cost and AccessNovember 1, 2005 Presented By: Margaret Nowak Avalere Health LLC

  2. Agenda The Evolution of Part D Plan Formularies • Classification systems • CMS review criteria • Timing of formulary changes • B vs. D

  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

  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

  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

  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

  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)

  8. Medicare Part D and the Benefit Design Options • 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 • 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

  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?

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