Coverage Decisions for Specialty Medications: Different Data, Different Determinations

ACPE UAN #:  0233-0000-17-009-H04-P

Release Date: March 28, 2017

Expiration Date:  March 28, 2020

Activity Type:    Knowledge-based

Contact Hours:  1.25

Activity Fee:  Member:  $15        Non-Member: $30

Target Audience: Pharmacists who practice in managed care settings.

Activity Overview

The United States health care system is fragmented, and this is very evident in drug coverage and reimbursement determinations made by individual payers. An analysis from a new database of more than 3000 coverage policies for specialty drugs found notable variation in the types of evidence that payers consider in their coverage determination, as well as the types of coverage offered. What are the implications of using different evidence when making these determinations? What do differences in the volume and composition of evidence used in coverage decisions mean for evidence generation? Do payers have appropriate and routine access to sound evidence to help inform medical policies?  This session will examine the evidence used by payers to make coverage and reimbursement determinations, and the impact of using different evidence to guide decision-making. 

Learning Objectives:  

At the completion of this activity, participants should be able to:

1. Explain how clinical evidence, health economics and outcomes research are utilized within medical policy decision-making on a population health level at managed care organizations.

2. Discuss challenges and opportunities faced by payers in applying, appraising and operationalizing evidence for coverage and reimbursement decisions.

3. Describe the impact that varying levels and sources of evidence have on payer decision-making for drug coverage and formulary placement. 

Schedule of Educational Activity

This activity consists of an audio recording, pre-test assessment questions (not required to pass or continue), post-test questions (required to pass with a score of 70% or higher) and a specific activity evaluation. 

CPE Requirements:   

Participants should claim continuing pharmacy education (CPE) credit for this home study activity only if they have not claimed credit for the live activity presented at the AMCP Annual Meeting 2017. 

CPE credit will be processed through the AMCP Learn portal and reported directly to CPE Monitor.  Please allow 72 hours for processing and posting in your NABP account. 

To receive credit for an online activity you must:

  • Review the full content of the activity.
  • Successfully complete the post-test (required to pass with a score of 70% or higher, it may be taken a maximum of three times).
  • Complete a specific activity evaluation.

System Technical Requirements/Viewing Requirements: System Requirements Courses and learning activities are delivered via your Web browser and Acrobat PDF. For all activities, you should have a basic comfort level using a computer and navigating web sites.  View the minimum technical and system requirements for continuing education online learning activities.

As an accredited provider, AMCP strictly adheres to the ACPE Standards for Commercial Support and other relevant guidelines and standards to ensure the independence of continuing pharmacy education (CPE) activities.  It is AMCP’s intent that all CPE activities be independent, objective, balanced, evidence-based and free of any commercial bias.


Joan Siegel, MS Pharm |  Corporate Accounts | CSL Behring Longwood, Florida

Credit Information

Activity Number Credit Amount Accreditation Period
ACPE UAN #0233-0000-17-009-H04-P 1.25 Contact Hours March 28, 2017 - March 28, 2020