Navigating formulary management

Health Benefits Report

By Kevin Lyons

In 2016, when we took the bold move of moving from an open formulary (all drugs that are FDA-approved for anything) to a national preferred formulary — a list of drugs that are separated and utilized based on their intended uses and costs — things went a little awry.

After a year or so, the division decided that it had the authority to change those lists, and to this day has, along with the pharmacy benefit manager, modified the list as it was adopted five years ago. Today it has become a web of different methods to save money, which I do believe they do to some degree, but words will pop up and you should know what they mean.

Step therapy: Step therapy is a process where before you receive a high-cost medication or even a different method of delivery of a medicine into the body, that you try lower-cost — and many times very effective — medicines first. Generally, prescribers listen to pharmaceutical reps who tout the performance of a drug over lunch, and never are told how much the drug costs.

Quantity limits: Some drugs are not prescribed for everyday use or are dangerous if taken more than they should be, and thus, there are quantity limits on the number of pills that one can receive in a month. Common categories are inhalers, migraine medicines, some pain management drugs and erectile dysfunction drugs. Some of these categories can be waived with the consent of your prescriber.

Prior authorization: Prior authorization makes sure that a drug is being used in the correct category and that the drug is the right drug for our member’s diagnosis. There is also an incentive to produce good outcomes for less cost. This is when a prescriber has to communicate with the pharmacy benefit manager, but at the end of the day, the right medicine is dispensed. It is sometimes cumbersome and never implemented in life-threatening scenarios.

What we have to remember is that doctors are not infallible, and 2 percent of our members are costing us 80 percent of our premiums. Doctors do not generally take into account what is the best option both medically and financially. If you don’t believe me, ask the doctor the next time they prescribe you a medicine how much it costs and what the clinical trials said about the drug. You will be surprised at some of their responses.