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Should payors determine what is on a formulary?

By Dennis Tribble posted 17 days ago


I just read in a newly released edition of Pharmacy Practice News where many practitioners believe that formulary content for high-cost drugs may be determined by payors. The notion in this article seemed to be that something should not be on the formulary if some payors will not pay for it or may require an extensive pre-approval process.

This seems to me to conflate to essentially unrelated issues:

  • Whether the drug is deemed useful and appropriate for use in the health-system
  • Whether the drug will be fully or partially reimbursed for particular patients

While cost-effectiveness is always part of the formulary decision, it seems to have been given a heightened prominence for these expensive therapies.

It does make sense to determine that such an expensive item should not be placed on a formulary if the Pharmacy and Therapeutics Committee (or its equivalent) determines that there are less expensive treatment options that are equally effective.

But if these treatments are unquestionably the best treatments for patient disease, then the formulary decision seems clear.

It seems sensible that placement of a drug on the formulary that is very expensive should not require the pharmacy to keep it in stock pending orders for its use. As nearly as I can tell, few, if any, of these treatments are unplanned.

Admittedly, non-formulary drugs are routinely administered in many hospitals. Making a drug non-formulary adds additional hurdles to the availability of the drug.

It seems to me that a formulary should represent the list of the best, most cost-effective drug therapies that a health system provides.

Determining if, and how, those therapies may be paid for should be a separate conversation.

What do you think?

As always, these thoughts are my own, and not those of my employer or of ASHP.

Dennis Tribble, PharmD, FASHP

Ormond Beach, FL