Question

What are 3 criteria used by payers in the US to determine if a drug can be covered under their plans?

What are the components of a Health Technology Assessment (HTA)? What are some of the institutes involved in HTA analyses in the United States?

Refer to Product X from the previous week’s pricing assignment: What are the typical coverage policies of national payers for the four drugs Vyvanse, Strattera, Amphetamine XR, and Methylphenidate (source: DRG Fingertip Formulary)? Based on these coverage policies, what may be possible coverage and restrictions in coverage for Product X at low, medium, and high end of your proposed price ranges?

Answer 1

what are the three criteria used by the payers in the US:

It include : public payers - government run agencies. private payers - commercial companies that sell health care insurance directly to individual, employers , unions.pharmacy benefit: administer prescription drug benefit,on behalf of payers.

Criteria are:1) the patients out of pockets costs are the same at all pharmacies in the payer's retail network.

2)the patient out of pocket costs are lower at a subset of pharmacies in the payer's network.

3) the patient must use the specific pharmacies or dispensing formats that payers designates.

components of health technology assessment:. It includes:

1) ontology: questions that an HTA should answer.

2) methodological guidance:how to answer the questioning guidance.

3) reporting structure:how to present the answers.

Institutes of HTA analysis:1)institute for clinical effectiveness and health policy.2) NIH - National institute of health.3) National HTA organization.

coverage policies of national payers for the four drugs (vyvanse , strattera , amphetamine xr, methylphenidate):

Attention deficit hyperactivity disorder is one the most common psychiatric conditions of childhood , affecting some patient throughout adulthood.due to the long record safety and efficacy stimulants ( methylphenidate, dextroamphetamine) are considered first line treatment of ADHD.there are several stimulants dosage formulations available,many which are available in generic form providing patients with many alternatives for the treatment of ADHD.

Boston medical center health plan- it includes offering health coverage plans to enrolled members. The plan operates in Massachusetts under the trade name Baston medical center health plan.

XR ( methylphenidate)- approval criteria ( mass health members)<18 years old need to meet the approval criteria under the PBHMI policy.