A Step Toward Clear, Consistent, Transparent Formulary Decisions

The process that health insurers use to determine health coverage is not always clear, making it hard for patients, providers and biopharmaceutical manufacturers to predict whether a particular treatment will be covered by a health plan.

The National Pharmaceutical Council recently worked with researchers from Cerner Research and the University of Pennsylvania to develop and test an approach to increase the clarity, consistency and transparency of formulary decisions. The results of the study, “Transparency in Evidence Evaluation and Formulary Decision-Making,” were published in the August edition of the journal Pharmacy and Therapeutics.

The research team worked with an expert panel to create an evidence assessment tool based on the elements of formulary decision-making: safety, efficacy, cost and evidence. The tool was validated with a large group of medical and pharmacy directors, and then piloted in a real-world pharmacy and therapeutics environment.

Although the tool showed promise during the validation process, it did not hold up during real-world pilot testing. Participants in the study said they did not feel the tool captured the dynamic and complex variables involved in the formulary decision-making process. While the first iteration of the tool did not take root, the research lays important groundwork for promoting greater transparency in formulary decision-making.

NPC is continuing to explore ways to enhance the processes used to evaluate evidence. In particular, NPC is working with the Academy of Managed Care Pharmacy (AMCP) and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) on a joint project called the CER Collaborative Initiative to provide greater uniformity and transparency in the evaluation and use of evidence for coverage and health care decision-making. The CER Collaborative is developing a user-friendly toolkit and training materials to help increase decision-makers’ awareness, understanding, and confidence in their abilities to critically appraise individual studies and synthesize the evidence from a variety of study methods to guide formulary decisions.

NPC invites you to join a webinar on September 10 at 1 p.m. ET to discuss the P&T study and its findings. Register for the webinar, “Can We Bring Clarity, Consistency and Transparency to Payer Coverage Decisions?” on NPC’s website.