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
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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