Formularies: Where Do We Go from Here?
Rupali Das, MD, MPH, FACOEM
Sr. Vice President, California Medical Director
Zenith Insurance Company
Roman Kownacki, MD, MPH, FACOEM
Medical Director, Occupational Health - Northern California
Kaiser Permanente
Outline
•Formulary information
•Design
•Predictions
•Recommendations
Formulary: More Than a List of Drugs
Principles of a Sound Drug Formulary System.
Academy of Managed Care Pharmacy, 2000
• Clinical and economic considerations
• Continually updated by experts and evidence-based process
• Aligns with treatment guidelines
• Policies & procedures: dispensing, appropriate utilization, etc.
• Incorporates cost containment strategies
Formularies in Group Health
•Widely Used
•Medicare/MediCal
•Benefit design e.g. Tiers
Formularies – Benefits vs RisksBENEFITS – proven or likely• Improves healthcare delivery
• Lower total drug costs
• Diminished use of inappropriate medications
• Lower UR costs
RISKS - potential• Patients LESS compliant with treatment
• Medical decision may not be patient-focused
• Increased burden for providers
• Increased UR or other administrative costs
Formulary Models
OPEN: a simple and non-exclusive listing of drugs covered
under the drug plan, frequently with various levels of cost-
sharing by the patient for some medications
CLOSED: only listed drugs are covered
HYBRID: in reality, most common model; non-listed drugs
are covered if necessity criteria are met
TEXAS
WORKER’S
COMPENSATION
FORMULARY
Based on ODG
Formulary Evidence Base Format and OrganizationGuidance on medical
conditions? Guidance onpre-authorization?
ODG ODG Guidelines AHFS listing None, except two exclusion types for
certain drugs
Drugs are either YES/NO;
Reed Group ACOEM Practice Guidelines Condition-triggered Yes: general condition, plus ICD-9/10 codes
Drugs are either “Recommended” or “Not recommended,”
Delaware Unstated 3 drug categories, with preferred / non-preferred
drugs
None Drugs are “Preferred” or “Not preferred”; “step care” for non-
preferred drugs
North Dakota Unstated AHFS listing (partial) None Drugs are: “OK, Non-formulary, or Prior Authorization“
Ohio Unstated AHFS listing (partial) None Separate listing of drugs requiring written prior authorization
Washington Unstated 19 drug categories None Drugs are: “OK, Non-formulary, or Prior Authorization“
Features of Existing Workers’ Compensation Formularies
Disputes over Pharmaceutical Treatment Pose Significant Burden
2015 IMR data https://www.dir.ca.gov/dwc/educonf23/UR-IMR/UR-IMR.pdf
Considerations for a state formulary
• Statutory requirements: AB 1124
• Effect of regulations
• Off the shelf or custom-crafted
• Impacts on existing processes and stakeholders
Rx Costs
UR/IMR(Frictional Costs)
Medical Quality
RISKS
RECOMMENDATIONS