There’s a LOT of activity around the country related to drug formularies. Four states (OH OK TX and WA) have implemented formularies and at least 4 more are considering doing so (CA, ME, MT, TN). (AR was scheduled to do so this year but pulled back)
The “Why?” is obvious; the proliferation of opioids, inappropriate prescribing of other drugs (Soma(r)), exploding volume of compounding, and rampant off-label use of drugs is seen as a major problem in work comp.
The “What”, as in, what formulary to use, is demonstrably not obvious.
There are (roughly speaking) three varieties of formularies;
- Open – pretty much any drug is available to anyone
- Closed – a binary, or yes/no formulary that is drug-centric
- Disease state/Condition-specific – formulary based on the underlying diagnosis and disease state (e.g. acute v chronic)
The closed formulary has some advantages – it is very simple and easy to understand, and from a regulatory perspective, administer and evaluate.
The closed formulary also has some rather significant issues.
- it starts with the drug, not the patient’s medical condition. This strikes me as backwards; guidelines should ALWAYS begin with the diagnosis.
- problems arise when “Y” drugs are dispensed, paid by the PBM, then the payer determines the drug is for an unrelated condition. Think antihypertensives, insulin replacements or asthma meds.
- it does not differentiate between acute and chronic stages of a disease or condition; treatment can be quite different for these different stages.
What does this mean for you?
While the closed formulary is easy to explain, it’s a lot tougher to manage on the back end for payers, PBMs, and prescribers alike.
And, while I’m no clinician, allowing antihypertensives and duragesic patches without a prior auth no matter the diagnosis, while requiring a PA for benadryl does seem problematic.