Pharmacoeconomic Analysis Summary
Section I. Drug Product
Product Information:
Brand Name/Manufacturer
Drug X Tablet USP (ACME Ltd.)
Generic Name/Strength/Dosage Form
Generic C 5 mg Tablet
DIN
01234567
Usual Dose Regimen/Duration
5 mg bid x 10 days
Submitted Price Per Unit
$ 2.00 per tablet
Daily Cost *
$ 4.00 per day
* based on usual dosing regimen and submitted price, as stated above
Available
Package Size (A)
Price (B)
50
100
500
$100.00
$200.00
$1000.00
Calculated
Price/Unit
(C = B/A)
$2.00 per tablet
$2.00 per tablet
$2.00 per tablet
Cost of Usual
Dosing Regimen
$40.00
$40.00
$40.00
Section II. Comparator Drug Product/Treatment
Price* Equivalent Dosing
Generic Name
Daily Cost
Regimen for
(Mfr)/Strength/Dosage
Comparator
Form
Generic A (Brand Y Inc.) 5 $1.00
5 mg bid x 10 days
$2.00
mg USP tablet
Generic B (Brand Z Inc) 5 $1.50
5 mg tid x 7 days
$4.50
mg BP capsule
*indicate source if other than the price in the Formulary/CDI.
Cost of Usual
Dosing
Regimen
$20.00
$31.50
Section III. Comparative Outcomes
Drug
Drug X
Generic A
Generic B
References:
Outcome1
(successes)
70%
80%
70%
Outcome 2
(adverse events)
5%
10%
10%
Outcome 3
(deaths)
1%
2%
3%
Outcome 4
(projected survival)
20 years
18 years
16 years
Note:
1. Appropriate comparators should be listed for each strength and dosage form.
2. The manufacturer should indicate comparable dosing regimens, including the
duration of therapy.
3. Where there are multiple source alternatives for the products, the lowest cost
interchangeable alternatives should be listed first.
4. Where there are listed single source alternatives for the product, these may also
be listed.
5. Where there are no appropriate listed single or multiple source alternatives, other
marketed drug products may be listed.
6. Where the appropriate comparison is not a drug but another treatment, please
attach a separate sheet outlining the treatment and indicating why it is the
appropriate comparator.
Section IV. Pharmacoeconomic Analysis
Pharmacoeconomic Analysis included? Yes/No
Pharmacoeconomic Worksheet included? Yes/No
If yes, Please indicate type of analysis:
1.
2.
3.
4.
5.
Cost-Minimization
Cost-Consequence
Cost-Effectiveness
Cost-Utility
Cost-Benefit
If a detailed economic analysis is not included, please outline the reasons.