Formulary for Prescription Medication Explained

What Is a Medication Formulary? Why Are Certain Medications Non-Formulary? What Are Formulary Tiers and Its Rules?
This Video Has the Answers.
Today's Video is a Fundamental of Healthcare Finance That Every Professional Must Understand... and that Most Consumers DO NOT.
The Formulary is the List of Medications That Are Covered by 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 Via Computer Software That They Use.
Formularies Have Many Rules Associated With Them:
1) Prior Authorization - Approval Must Be Given by the Health Insurance Company/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.
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[@tonysaxman]

You explained exactly what I needed - thank you so much for being so professional, well-versed and highly thorough.

[@ahealthcarez]

Thank you for watching.

[@marir3126]

Currently a CVS pharmacy tech and student. Insurance makes me feel rabid but this explanation will definitely help me calm my even more rabid patients. Thanks so much.

[@ahealthcarez]

You bet! Thank you for watching!!

[@CharlieSpecter]

Love your videos. Keep them coming!

[@ahealthcarez]

Thank you for watching and for your encouragement.

[@patrickyoakum1180]

It looks like a few others already beat me to it so I won’t comment on the fact that retail pharmacists are almost completely in the dark about the formulary. On the bright side, EHRs incorporate Real Time Prescription Benefits functionality in what OP prescribers use now!

[@ahealthcarez]

Thank you for watching and weighing in with your thoughts.

[@Ilovebluey]

I work at bcbs and I’m having a hard time understanding this

[@ahealthcarez]

Thank for for watching and for your feedback. I’ll work on doing a better job.

[@CharlieSpecter]

Can you do a video on 340b pricing and how they tie in to the PBM industry?

[@ahealthcarez]

Sure. Here is one I already made: czcams.com/video/0UPOC67WTds/video.html

[@jungseo3468]

Quite the upgrade!

[@ahealthcarez]

The feedback on the screen vs. the white board has been mixed.
Can’t please everybody. 🤷‍♂️
Thank you for watching.

[@jdean813]

@@ahealthcarez - it's all about the content for me, and you provide it so well, Dr. Bricker. Thank you!

[@grudgerun]

@@ahealthcarez Count me on Team Whiteboard!

[@cumbara4595]

Thanks for your videos. You explained doctors does not know formulary. But, when it comes to specialty drug, such as Humira that usually PA drug or step therapy drug, does doctors usually know that these kind of drugs need to confirm patient's formulary or call PBM/insurance before prescribing? Otherwise, likewise other drugs, does the pharmacy notice prescriped specialty drugs should confirmed PA status?

[@ahealthcarez]

Yes, rheumatologist sand GI doctors generally know. Thank you for your question and thank you for watching.

[@genevachew315]

If it's on the formulary and you a PA and it's still not being covered why is this ?

[@ahealthcarez]

Could be that you have a high deductible plan and medications count towards your deductible, which you have not met yet. Not sure.

[@s1monxsayz325]

Pharmacist don’t actually know the formulary. They need to bill patient’s insurance to see if a given drug is covered

[@ahealthcarez]

Thank you for the clarification.
Appreciate you watching.