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January 26, 2021
Breast cancer killed more than 42,000 Americans in 2020, according to the American Cancer Society. Triple-negative breast cancer is an aggressive form of the disease with few treatment options. That’s why it seemed good news when in March 2019, the Food and Drug Administration (FDA) approved the drug Tecentriq for treatment of this aggressive cancer.
Before approving any drug for coverage, our clinical team conducts a comprehensive evaluation of scientific studies on effectiveness in patients. In the case of Tecentriq as a treatment for triple-negative breast cancer, studies showed no evidence of improved clinical outcomes and in fact showed increased risk of adverse effects in patients. That was the basis of our decision not to cover the drug for this disease. It was a potentially controversial decision, but one made with our members’ health and welfare as our primary concern.
Turns out the FDA agrees. In September 2020, it issued a warning to providers stating that subsequent evaluation of the drug demonstrated it was not effective in treating triple-negative breast cancer.
At its most basic level, a formulary is a list of drugs covered under a health plan and how much the member will pay. It also identifies drugs that may need to go through additional steps, such as pre-authorization, before the health plan covers them.
All health plans and PBMs have their own formularies that they claim to be best. How is a customer to know? It’s critical to understand how formularies are developed and what their goals are. Are they created by clinicians or accountants? Do they provide the best care and value to members and clients, or are they built to help the bottom line of health plans, PBMs or shareholders?
As a nonprofit health plan, our formularies are built to serve those we serve: members and customers.
Before we are confident about including a drug on our formularies, we conduct an extensive, research-driven, clinical and value assessment of every drug on the market. We look at patient outcomes as well as the overall value of each drug and its impact on total health care costs.
Not only do we examine scientific studies, we take it a step beyond standard industry process. Our clinicians evaluate each drug to determine its Net Health Benefit (NHB)—a rating system developed by ICER, an independent and internationally renowned research organization that provides clinical and economic evaluations. The NHB is a leading-edge system that guides our clinicians’ examination of the overall body of evidence for a drug compared to similar drugs for the treatment of a particular disease. This extra review adds a rigorous and consistent process that considers a drug’s clinical effectiveness, safety and impacts on the total cost of care.
The final assessment of a drug is presented to our Pharmacy and Therapeutics (P&T) Committee, a group of independently practicing physicians and pharmacists from across our footprint, along with a lay person from the community and a medical ethicist. This group of experts reviews the research and votes on the strength of evidence and value of each drug, which provides the parameters for the final build of the formularies.
Asuris was one of the first health insurance companies to standardize the evidence-based approach to evaluating new drugs for coverage. As a result, we were recognized by ICER for excellence in practice and application of a multidisciplinary approach to informed formulary decision-making.
Our philosophy in formulary drug management is rooted in a strong, clinical perspective to provide high value for our members both clinically and financially. We strive to stay ahead of the curve in our strategic approach to provide access to high-quality drugs while also focusing on cost stewardship for our clients and members.
As a tax-paying non-profit, we’re committed to bring value to our members, customers, and communities in all our products and services. When you choose a prescription plan from Asuris you know it’s backed by pharmacists and physicians and guided by what’s best for the people it serves.