Download Outcomes-Based Drug List Selection Process

ProVIDER education
Outcomes-Based
Drug List Selection
Process
Our unique process combines rigorous critical
appraisal of literature with real-world data.
The result is an outcomes-based drug list
containing medications with proven benefit
for patients.
ProVIDER education
Our drug list (also referred to as a formulary) is created by the
Pharmacy and Therapeutics (P&T) Committee, which consists of
two subcommittees: the Clinical Review Committee (CRC) and
the Value Assessment Committee (VAC). The CRC consists of a
large group of independently practicing clinicians representing
diverse specialties who are not employed by this company or its
subsidiaries. The VAC is made up of company-employed physicians, pharmacists, and analysts representing both clinical and
business perspectives. Together, these groups combine clinical
evaluation and value-based decision-making to determine the
medications included on our drug list.
Clinical evidence meeting quality criteria in
more than 25 areas are considered for each
review, which helps ensure that data of the
highest quality are shaping each decision.
Three well-defined steps guide this process:
1. Clinical review - the foundation of our drug list
2. Value assessment - considering the value each drug brings
to our drug list
3. Tier placement - determining coverage levels within tiers
Clinical review
The internal drug information team gathers and critically
appraises all available clinical data, including:
• Published literature, e.g., practice guidelines, systematic
reviews, meta analyses and clinical trials
• Food and Drug Administration documents, e.g., medical
reviews and safety updates
• Manufacturer information, e.g., product labels, dossiers
and presentations
Each piece of clinical data is critically appraised for quality
using a rigorous evidence-based process. Evidence meeting
quality criteria in more than 25 areas, including appropriate
study design and methodology, acceptable subject drop-out
rates and handling of missing data, are considered for inclusion
in each review. Emphasis is placed on reporting of clinically
important improvements and evaluation of patient-oriented
outcomes (e.g., cardiovascular event rate reduction) instead of
disease-oriented or surrogate endpoints (e.g., blood pressure
lowering) – which helps ensure that data of the highest quality
are shaping each decision.
The clinical evidence for each drug is compared with that of
similar drugs based on effectiveness, efficacy, safety and clinical
attributes – drug-related characteristics important to prescribers
and patients. Recommendations from specialty physicians and
advisory panels are often gathered and included, and each drug
receives a clinical ranking from the CRC based on the presented
evidence. Additionally, the clinical appropriateness of our
programs and initiatives, designed to help promote nationally
recognized, effective and proven utilization of pharmacy benefits,
is also reviewed.
Value assessment
The following information is provided to the VAC to determine
drug list placement of each drug under review:
• Clinical rankings and comments for each drug determined by
the CRC
• Real-world health outcomes data (internal and external)
• Total cost of care analyses, including pharmacy, medical and
laboratory data (internal)
• General financial modeling
Internal analyses are carefully reviewed by a panel of external
pharmacoeconomic specialists before being reported to the VAC.
2 | Outcomes-Based Drug List Selection Process
The VAC considers clinical ranking first to dictate tier placement
options for each drug, followed by careful consideration of health
outcomes information, financial data and other potential impact
factors to further shape final tier placement decisions.
Tier placement
The last step in drug list development is assigning a coverage
level using tiers – groups of drugs that fall within description and
pricing groups.
• Tier 1, usually limited to generic drugs, has the most
affordable coinsurance payment, or copay.
• Tier 2 and Tier 3 are often comprised of brand name drugs
or more expensive generics, and cost slightly more.
• Tier 4, commonly reserved for specialty drugs, has the highest
copay amounts.
An outcomes-based drug list
Our drug list development process is involved. Critical
evaluation of clinical evidence is integral and foremost in the
process, and establishes the foundation for each drug list
decision. Our value assessment process is unique and includes
not only cost data, but also real-world outcomes and total cost of
care information from a database of 35 million people – one of
the largest in the world.
We are confident that our robust evaluation process allows us to
reach our goal of developing an outcomes-based drug list that
includes medications of the highest clinical value, ultimately
improving the health of our members.
How our clinical review and value assessment process
shaped two important drug list decisions:
• Bisphosphonates medication class review results
indicated that the medications with the best clinical
trial data also demonstrated lower fracture rates and
lower total cost of care. These were the medications
chosen for and included on our drug list.
• Our analysis showed that members with COPD taking
more expensive medications had fewer emergency
room and hospital visits than those taking less expensive
medications. The expensive medications also had
the best clinical trial data. They were placed on the drug
list because they are best for members and decrease
overall cost, despite availability of less expensive
treatment alternatives.
Outcomes-Based Drug List Selection Process | 3
Still have questions?
Visit the Providers page of bcbsga.com
for more information about the drug list.
Blue Cross and Blue Shield of Georgia, Inc., is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the
Blue Cross and Blue Shield Association. Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al
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