Covered California 2016 proposed actions on drug formularies

During Thursday’s board meeting, Covered California 2016 proposal actions regarding formularies were announced. These included:

  1. Expanded Transparency and Access
  2. Standardized Formulary Tier Definitions
  3. Establish Clear Requirements for Access to Chronic
    Care Drugs Across Tiers
  4. Assess Implementation of Caps or Spreading of Maximum Out-of-Pocket Throughout the Year

You can read the entire presentation online.

1. Expanded Transparency and Access
Covered California proposes to impose additional requirements on its QHPs in 2016, including:

  • Plans to have an opt out retail option for mail order (allowing consumers that want/need in-person assistance to get such service at no additional cost)
  • Plans to provide estimate of enrolled consumer range of costs for specific drugs
  • Include statement on the availability of drugs not listed on the formulary
  • In tiers 1 – 4, the plans must include all of their formulary covered drugs used to treat HIV/AIDS, Hepatitis C, Rheumatoid Arthritis, Multiple Sclerosis, Systemic Lupus Erythematosus
  • Exception process written clearly on formulary
  • All drugs that are covered in Tier 4 mist be listed on the formulary (not just the Top 50 or highest use drugs)
  • Dedicated pharmacy customer service line where advocates and prospective consumers can call for clarification

An overview of the Covered California 2016 standardized formulary tier definitions was shown:

1A) Most generic drugs and lost cost preferred brands
2A) Generic drugs - non-preferred
B) Brand name drugs - preferred
C) Recommended by the plan's P&T committee based on drug safety, efficacy, and cost
3A) Brand name drugs - non-preferred
B) Recommended by P&T committee based on drug safety, efficacy, and cost
C) Generally have a preferred and often less costly therapeutic alternative at a lower tier
4A) Drugs that are I) FDA or drug manufacturer limits distribution to specialty pharmacies or II) self administration requires training, clinical monitoring or III) Drug manufactured using biotechnology
B) More costly than other drugs (minimum baseline for cost is >$600)

Access to Medications for Chronic Conditions

If a drug would otherwise qualify for placement on Tier 4 and at least 3 treatment options are available for that particular condition, the Covered California 2016 proposal suggested that one drug for that condition must be placed on either tier 1, 2, or 3. The goal is to alleviate cost burdens for chronic conditions like HIV/AIDS, hepatitis C, rheumatoid arthritis, multiple sclerosis, and lupus.

Here are some of the scenarios being discussed currently:
Covered California 2016 Proposed Caps


We recommend reading the entire presentation online.