Developing Prioritization Criteria to Identify Target Drugs for CalRx, the California Generic Drugs Initiative

Published:November 12, 2022DOI:


      • In January 2020, Governor Gavin Newsom announced the creation of CalRx, a California-sponsored generic drug label. CalRx aims to lower prices and increase access to pharmaceuticals in California. The question became how to establish criteria to identify priority drugs for CalRx.
      • This article describes the development of prioritization criteria to CalRx based on a review of the literature and a ranking exercise with key stakeholders. We found that drugs that treat large populations, drugs that represent large costs to payors, and drugs that represent large costs to consumers should be the priority for California’s CalRx generic drug initiative.
      • By detailing the collaborative process involved in developing the CalRx prioritization criteria, this article models inclusive policy design and implementation in public health decision making. The final set of criteria identified can also help inform prioritization efforts for future initiatives targeting prescription drugs at the state level and beyond.



      This study aimed to establish criteria to identify priority drugs for CalRx, a California-sponsored initiative to support the manufacture and distribution of affordable generic drugs.


      A web-based ranking exercise was implemented with key stakeholders in August 2020, using pricing, spending, and public health criteria identified through a review of academic literature and public health agency reports. A total of 39 of 40 invited stakeholders in 4 different categories—patient advocates, healthcare providers, health insurers, and health policy and economic experts—participated in this study (98% response rate).


      Drugs that treat large populations, drugs that represent high cost to payors, and drugs that represent high cost to consumers were ranked a priority, receiving > 10% of ranking weights. Drugs that treat conditions with high morbidity or mortality, drugs without therapeutic alternatives, and drugs treating vulnerable populations represented criteria of further interest (9%-10% of weights). Shortage risk and curative effect (8%-9% of the weights), high price increases, communicable disease treatments, and high unit prices (< 8% of the weights) represented the bottom of the priority distribution.


      This study suggests that drugs that treat large populations, drugs that represent large costs to payors, and drugs that represent large costs to consumers should be the priority for California’s CalRx generic drug initiative. A prioritizing algorithm will assist California in determining top drugs to target from a public health and spending perspective as it plans the rollout of the CalRx initiative and negotiates with drug manufacturers.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Value in Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • The case for competition
        2019 generic drug & biosimilars access & savings in the U.S. report. Association for Affordable Medicines.
        Date accessed: August 11, 2022
        • Tessema F.A.
        • Kesselheim A.S.
        • Sinha M.S.
        Generic but expensive: why prices can remain high for off-patent drugs.
        Hastings L J. 2019; 71: 1019
        • Generic drugs under Medicare
        part D generic drug prices declined overall, but some had extraordinary price increases. United States Government Accountability Office.
        Date accessed: August 11, 2022
        • Governor’s budget summary 2020-2021
        The Department of Finance, State of California, Health and Human Services.
        • Beam A.
        California could be 1st state to sell own prescription drugs. AP News.
        • California Senate Bill 852
        California Legislative.
        • Generic drugs
        questions & answers. United States Food and Drug Administration.
      1. SurveyMonkey survey platform. Accessed August 01, 2020.

        • Aragon T.J.
        Deriving criteria weights for health decision making: a brief tutorial. UC Berkeley: School of Public Health.
        Date accessed: January 29, 2022
        • Dolan J.G.
        Shared decision-making–transferring research into practice: the Analytic Hierarchy Process (AHP).
        Patient Educ Couns. 2008; 73: 418-425
        • Dolan J.G.
        Multi-criteria clinical decision support: a primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare.
        Patient. 2010; 3: 229-248
        • State of California budget change proposal 4140-079-BCP-2022-A1 reducing the cost of insulin: CalRx biosimilar insulin initiative
        Department of Health Care Access and Information.
        • IRB Policies
        Updated and Approved 22Nov2019. Policy No. 102.01-“Not Human Subjects Research” Activities. Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB).
        • Bodenheimer T.
        The Oregon Health Plan–lessons for the nation. First of two parts.
        N Engl J Med. 1997; 337: 651-655
        • Perry P.A.
        • Hotze T.
        Oregon’s experiment with prioritizing public health care services.
        Virtual Mentor. 2011; 13: 241-247
        • Comparison of state prescription drug affordability review initiatives
        National Academy for State Health Policy.