Test 3 Formularies Flashcards
What is a P&T committee?
Policy-recommending body to an organization regarding the therapeutic use of drugs
Define formulary
A formal, organizationally sanctioned, dynamic system which uses an expert panel to continuously and objectively evaluate and select appropriate drug products based on effectiveness, safety and cost.
Purpose of a Formulary System
- To provide a precise system for monitoring drug use and drug therapy management
- To provide safe, appropriate, effective, and economical use of drugs
Formulary vs Non-Formulary
- Open Formulary
- Incentive Formulary
- Closed Formulary
Open Formulary
formulary and nonformulary drugs are covered at the same benefit level (copays vary)
Incentive Formulary
member pays a higher copay or coinsurance for non-formulary drugs
Closed Formulary
member pays applicable copay or coinsurance for formulary drugs; non-formulary drugs are not covered
What is the purpose of a tier structure?
- to differentiate between preferred and non-preferred
- Tier one: preferred generic or rebated products
- Tier two: preferred brand
- Tier 3: non-preferred
What is step-therapy?
- encouraging you to try a specific product before you can try another product
- prior auths may be required for certain steps
- based on clinical guidelines
3 goals of a formulary system
- Foster safe, appropriate, and effective drug therapy
- Contribute to the education of the providers in the network
- Achieve some degree of cost containment
How does the formulary system achieve their goals?
- Formulary additions and deletions
- Drug product selection (generic usage)
- Access to non-formulary / higher tier drugs
- Processing non-formulary / higher tier requests
- Therapeutic interchange
- Off-label usage
- Experimental drugs
- High-cost/breakthrough drugs
- Exclusions
- Maximum allowable supply / length of therapy
excluded vs nonformulary
- excluded not covered
- non-formulary may be covered
What are the steps in developing a preferred product list?
- Review all available efficacy and safety data on the selected drug category
- Review practice guidelines and/or seek opinions of leaders in the field
- Prepare list of acceptable lower tiered products
- Review cost (and rebates if applicable) for entire drug category
- Determine final tier structure based on efficacy, safety, and cost data
- Develop criteria for moving between steps
- Educate providers and members
- Implement new tier structure
- Review outcomes/results
