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