Topic

Reimbursement and managed access

Once a technology has been assessed, payers decide how it will be paid for and on what terms. Managed entry agreements tie funding to price discounts, outcomes or further data collection, while insurers control use through a formulary and prior authorization, supported by evidence packages such as the AMCP dossier.

Concepts in this topic

• AMCP DossierThe AMCP dossier is a manufacturer's evidence package, built to AMCP's Format for Formulary Submissions, that US health plans use in formulary decisions.
• Appeals DesignAppeals design is the set of rules for contesting a health insurer's coverage denial: filing windows, deadlines, review levels and independent review.
• FormularyA list of medications approved for coverage by a health plan or system, often organised into tiers reflecting patient cost-sharing levels.
• Managed Entry AgreementAn arrangement governing the conditions under which a technology enters the market, often incorporating outcomes-based payment or coverage with evidence development.
• Prior AuthorizationA health plan’s advance review of a patient-specific service, medicine or item against coverage criteria before it is provided.