Plan/Company name: ___ (for in-house use only)

Please list the total number of covered/managed lives serviced. ___

What is the composition (number of members) of your P&T committee:

1. Pharmacists ___

2. Physicians ___

3. Other Healthcare Professionals ___

Regardless of the existence of a formulary or a system of nonformulary prior authorizations for exceptions, how many covered lives are enrolled in plans that exclude the following drug classes for reimbursement as a benefit design restriction:

DESI drugs? ___

Experimental drugs ___

Off-label use? ___

OTC? ___

Cosmetic drugs or life-style drugs? ___

Other? (please specify the drug class) ___

How many covered lives are in plans with:

1. 1–2 excluded classes? ___

2. 3–5 excluded classes? ___

3. >5 excluded classes? ___

How many covered lives are in plans that have a pharmacy benefit with a closed or partially closed formulary; that is, a formulary that limits and requires justification for use of drugs not listed on the formulary independent of those drugs excluded through benefit design? ___

How many covered lives are in plans with: (See top of page 2 for definition)

1–2 closed classes? ___

3–5 closed classes? ___

>5 closed classes? ___

(That is, classes in which some drugs are not listed on the formulary, are not covered or reimbursed, and can be obtained only through a nonformulary exceptions process.)

How many covered lives are in plans with closed classes that contain only one drug? ___

What are the closed classes in your plans? ___ ___ ___

Which processes are in place in closed formulary environments to allow for access to nonformulary drugs? (check all that apply)

None, all nonformulary drugs are not covered. ___

Nonformulary drugs may be covered through an informal exceptions process. ___

Nonformulary drugs may be covered through a formal prior authorization process. ___

Other, describe. ___

How many covered lives are in plans that have nonclosed formularies but have preferred classes, that is, classes in which there are drugs whose use is encouraged by incentives (lower copay, academic detailing, DUR, soft edits), or usage criteria, or in which prescribing of nonpreferred drugs is discouraged. ___

How many covered lives are in plans with:

1–2 preferred classes? ___

3–5 preferred classes? ___

>5 preferred classes? ___

What are the preferred classes in your plans? ___

How many covered lives are in plans where an open formulary is used but the items listed are only passively promoted (use of educational materials, few soft edits)? ___

How many covered lives are in plans:

that have no formulary, but selected drugs are labeled as “Require Prior Authorization?” ___

that have no formulary or prior authorization process, but pharmacists perform DUR and physicians are notified when inappropriate use is identified? ___

that have no formulary, no controls, or no checks on physician practice patterns. All drugs go through as covered and access is open? ___

How many covered lives are in plans that restrict coverage or reimbursement of specific drugs or classes of drugs to specific prescribers, settings, or disease conditions? ___

How many covered lives are in plans that require generic substitution? ___

How many covered lives fall under formulary systems which:

Have a nonformulary exceptions process for coverage? ___

Use copay design controls to influence use of nonformulary drugs? ___

How many covered lives fall under plans whose system edits include:

Limits on numbers of prescriptions per patient at any time or per unit time?

Limits on refills of prescriptions (number of drugs with such limits)? ___

Limits on duration of use of some drugs (number of drugs with such limits)? ___

Limits on the supply of drugs per prescription or on hand? ___

Presence of a prior approval process for some drugs (number of drugs requiring prior approval)? ___

How many covered lives are in plans that limit formulary addition of new FDA-approved drugs by requiring waiting periods? ___

How many covered lives are in plans that require waiting periods of more than 6 months? ___

Do any enrollees participate in plans that have policies in place to actively review or monitor activities at the FDA such that reviews of new drugs are done concurrently (proactively) with FDA approval?

Yes ___ No ___

If yes, the number of covered lives in plans that proactively review/monitor for new AIDS/cancer medications. ___

If yes, the number of covered lives in plans that proactively review/monitor for new FDA “1P” drugs. ___

If yes, the number of covered lives in plans that proactively review/monitor for new FDA “standard” designation drugs. ___

How many covered lives are in plans that:

have an internal appeals process for denials of drug coverage or reimbursement for excluded drugs? ___

have an internal appeals process for denials of nonformulary drug requests? ___

have an appeals process subject to independent external review? ___

1. How many covered lives are in plans that provide continuation of coverage after removal of a drug from the formulary? (Choose which one applies)

   Policy applies to a few specific drugs. ___

   How many covered lives? ___

   Policy applies to all drugs. ___

   How many covered lives? ___

2. Are there financial penalties incurred by patients? (Please describe)

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