Formularies -- What drugs are covered?
December 10, 2015 9:11 AM Subscribe
Working on a project, and I'm trying to figure out what drugs may or may not be on a formulary.
For example, trimethoprim/sulfamethoxazole (generic for Bactrim) is on every formulary I've looked at on Epocrates. Viagra is on no formulary. What are drugs that are a large variance about whether they are on a particular plan's formulary or not? It seems like this should be accessible on Epocrates but I can't figure it out. Ideally, I'd be able to look up a drug and there would be a table with all the formularies it's on in one column, and its tier in the next column. I'm willing to do some manual data comparison to get to the answer if necessary. However, I have a list of about 50 drugs that I need this info about so heavy data extraction is time-prohibitive.
If you imagine a Venn diagram with circle A as on all formularies, and B is excluded from all formularies, I'm looking for those in the intersection.
Bonus points: to introduce a level of complexity, a three part Venn would be helpful too: A as on all, B as medications needing prior authorization for all formularies, and C is excluded from all formularies.
For example, trimethoprim/sulfamethoxazole (generic for Bactrim) is on every formulary I've looked at on Epocrates. Viagra is on no formulary. What are drugs that are a large variance about whether they are on a particular plan's formulary or not? It seems like this should be accessible on Epocrates but I can't figure it out. Ideally, I'd be able to look up a drug and there would be a table with all the formularies it's on in one column, and its tier in the next column. I'm willing to do some manual data comparison to get to the answer if necessary. However, I have a list of about 50 drugs that I need this info about so heavy data extraction is time-prohibitive.
If you imagine a Venn diagram with circle A as on all formularies, and B is excluded from all formularies, I'm looking for those in the intersection.
Bonus points: to introduce a level of complexity, a three part Venn would be helpful too: A as on all, B as medications needing prior authorization for all formularies, and C is excluded from all formularies.
this question has some weird cultural context. i guess most people must understand, but for the record, are you talking about hospital formularies, health system formularies, insurance formularies, or something else?
wikipedia
posted by andrewcooke at 9:38 AM on December 10, 2015 [3 favorites]
wikipedia
posted by andrewcooke at 9:38 AM on December 10, 2015 [3 favorites]
First, there are transients. When the first generic for a brand comes out, the brand drug will not disappear from all formularies at the same time. It will take a few months for all to switch.
Second, its possible that two formularies will both have the same med, but not for all the same dosage levels. I know of a case where a formulary would pay for .50mg and 1.0mg, but not for three .25 which was awkward if .75 is your preferred dose.
Third, in the US, formularies are required to cover all psych drugs because they are not pure substitutes for each other.
Fourth, coverages different for injectable. These tend to be very expensive, which is one reason, but it may be that it's because the get covered under kinds if insurance.
posted by SemiSalt at 9:47 AM on December 10, 2015 [1 favorite]
Second, its possible that two formularies will both have the same med, but not for all the same dosage levels. I know of a case where a formulary would pay for .50mg and 1.0mg, but not for three .25 which was awkward if .75 is your preferred dose.
Third, in the US, formularies are required to cover all psych drugs because they are not pure substitutes for each other.
Fourth, coverages different for injectable. These tend to be very expensive, which is one reason, but it may be that it's because the get covered under kinds if insurance.
posted by SemiSalt at 9:47 AM on December 10, 2015 [1 favorite]
Yeah... If you are looking at even a subset, say, state Medicaid formularies, there will be a different formulary/PDL for every state and what's in them will vary based on pricing and plan coverage.
posted by mochapickle at 9:48 AM on December 10, 2015 [3 favorites]
posted by mochapickle at 9:48 AM on December 10, 2015 [3 favorites]
There are also some drugs that are approved for more than one usage but will only be covered under certain diagnosis codes.
Retin A is one example: it's often covered for acne but almost never covered for wrinkles.
posted by littlewater at 9:59 AM on December 10, 2015 [1 favorite]
Retin A is one example: it's often covered for acne but almost never covered for wrinkles.
posted by littlewater at 9:59 AM on December 10, 2015 [1 favorite]
I think one issue is that there is no standard set of tiers. Some plans may use three, four, or five tiers and the co-pay difference between them will vary as well. If you're looking to compare different tiers, you'll need to figure out a way to standardize them.
posted by zachlipton at 10:00 AM on December 10, 2015 [1 favorite]
posted by zachlipton at 10:00 AM on December 10, 2015 [1 favorite]
If we're talking about the US, you need to take into account whether the plan you're viewing is self insured or fully insured.
Also, corporations can occasionally choose to include or not include drugs on their formulary. For instance, Advair 100/50 may be on formulary for Corporation A using BCBS X, but not on formulary for Corporation B using BCBS X.
posted by RogueTech at 10:14 AM on December 10, 2015 [3 favorites]
Also, corporations can occasionally choose to include or not include drugs on their formulary. For instance, Advair 100/50 may be on formulary for Corporation A using BCBS X, but not on formulary for Corporation B using BCBS X.
posted by RogueTech at 10:14 AM on December 10, 2015 [3 favorites]
Drugs that are still brand-only but where there are several similar "me-too" drugs in the class often have a large variation in terms of coverage. Usually insurance companies will have a deal with one of the manufacturers, so that formularies preferentially their product at a lower tier, but it's a pain in the neck trying to remember which one is which.
Statins: everyone will cover the cheap generics like lovastatin and simvastain. Coverage of atorvastatin (Lipitor) and rosuvastatin (Crestor) will likely be more variable, although now that atorvastatin is generic this may be less of an issue.
Diabetes medications. Everyone covers metformin. Look at the DPP-4 inhibtors like Januvia (sitagliptin) Onglyza (saxagliptin) and Tradjenta (linagliptin). Usually formularies will have one of these as a Tier 2 and the others as Tier 3 or non-covered.
oral anticoagulants: Rivaroxaban (Xarelto) is probably the most popular. After that, dabigatran (Pradaxa) and apixaban (Eliquis) have more variable coverage.
fluoroquinolone antibiotics, specifically the ones with respiratory coverage: Levaquin (levofloxacin) vs Avalox (moxifloxacin).
The only medications I can think of that are typically excluded from all formularies are the erectile dysfunction drugs. Almost everything else you can get with prior authorization, it just depends on how much documentation you need
posted by The Elusive Architeuthis at 11:14 AM on December 10, 2015
Statins: everyone will cover the cheap generics like lovastatin and simvastain. Coverage of atorvastatin (Lipitor) and rosuvastatin (Crestor) will likely be more variable, although now that atorvastatin is generic this may be less of an issue.
Diabetes medications. Everyone covers metformin. Look at the DPP-4 inhibtors like Januvia (sitagliptin) Onglyza (saxagliptin) and Tradjenta (linagliptin). Usually formularies will have one of these as a Tier 2 and the others as Tier 3 or non-covered.
oral anticoagulants: Rivaroxaban (Xarelto) is probably the most popular. After that, dabigatran (Pradaxa) and apixaban (Eliquis) have more variable coverage.
fluoroquinolone antibiotics, specifically the ones with respiratory coverage: Levaquin (levofloxacin) vs Avalox (moxifloxacin).
The only medications I can think of that are typically excluded from all formularies are the erectile dysfunction drugs. Almost everything else you can get with prior authorization, it just depends on how much documentation you need
posted by The Elusive Architeuthis at 11:14 AM on December 10, 2015
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My recommendation would be to select a representative sample of formularies (you decide what number of formularies you're comfortable working with) and then query each one for each of your 50 drugs. You won't get a definitive answer but if your question is "which of these drugs are not universally on formulary/off formulary?", you'll get a pretty good approximation.
I'm not sure what the context is of your project, but if you have students available to you at all, these are the kinds of manual data extraction projects that I (happily!) completed for professors and grad students when I was in school.
posted by telegraph at 9:27 AM on December 10, 2015 [1 favorite]