Formulary for Prescription Medication Explained
This is the second video from Dr. Eric Bricker we publish on our site: What you should know about your pharmacy benefits.
Dr. Bricker wrote an abstract of the video with following key take-aways.
What Is a Medication Formulary? Why Are Certain Medications Non-Formulary? What Are Formulary Tiers and Its Rules?
The Formulary is the list of medications covered by your health insurance. Not all medications are covered.
The Doctor does not know what medications are or are not on their patients’ Formularies.
However, the Pharmacy does, through the computer system they use.
Formularies have many Rules associated with them:
1) Prior Authorization – Approval must be given by the health insurance / PBM before they agree to pay for a medication.
2) Step Therapy – Certain less expensive generic medications have to be ‘tried’ first and fail before a Doctor can prescribe a more expensive brand-name medication.
3) Mandatory Generics – If a brand-name medication has a direct generic equivalent, then the insurance may only agree to pay for the generic and not the brand.
4) Mandatory Mail-Order – Certain chronic medications that are filled for 90 day supplies must be filled via Mail-Order and not at the retail Pharmacy.
Thank you for watching and feel free to check out other videos that Dr. Bricker posts on his website.