- places a limit on a drug given that the plan sponsor will allow completion in a certain amount of time.
- these limits are set according to the prospectus.
- addresses safety and cost concerns, as well as drug overuse.
- step therapy
- trying different medications in a series of steps.
- start with the safest and most cost-effective drugs and work your way up to riskier or more expensive drugs.
- the patient must fail two or three treatments before the more expensive drug is approved.
- wait for the doctor to complete the prior authorization.
- this could be approved or denied.
- pay the full cash price of the prescription (i.e., not use the prescription plan benefit).
food to go
Early in my career as a retail pharmacist, I did not fully understand why these policies were in place and this made it difficult for me to explain to the patient what was happening. patients are overwhelmed and upset when told their prescription is not covered.
As I have gained more experience, this has all changed. patients were still very upset, but being able to better explain the process to them made a big difference to them.
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most of the time the patient would wait until the medication was approved. the other times we would fill the medication in cash and then rebill it after it was approved and return the difference to the patient.
What I took away most from learning about these policies and procedures is that they were put in place to provide the best patient care. patients think that cost is the only determining factor, which is not the case.
Each formulary has the evidence to support why a drug is included or excluded. Explaining that to the patient is difficult, but it’s a much better response than “insurance doesn’t want to pay for that.”
pbm protects the patient, the plan sponsor and themselves.
about the author
ryan fitzmaurice earned his doctorate in pharmacy from lake erie college of osteopathic medicine (lecom) school of pharmacy and earned his master’s degree in pharmaceutical business administration (mpba) program at The University of Pittsburgh, a 12-month executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the drug business. She has spent the last several years working in the industry, including managing retail pharmacies, specialty pharmacies, and 340b pharmacies.
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Patients are often upset when told that their prescription calls for one of these at the pharmacy counter. They will say that the doctor knows better and that there is a reason this medicine was prescribed.
While this may often be true, patients may not always be aware of drug costs. These um policies exist to maintain patient safety, to be cost-effective for the plan, and to ensure that medication use is clinically appropriate.
Reading: Why won t my insurance cover my medication
As a retail pharmacist, too often I’ve had to explain to patients what this whole process is all about. the most common utilization management is prior authorization.
pbm wants to ensure that the drug selected is appropriate for the patients’ specific disease state. it can also occur when a non-formulary drug has a medical necessity.
what are the options if a recipe calls for one of these?
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each scenario returns to the prescriber. The prescriber will need to submit documentation to the pbm as to why the specific drug is needed for prior authorization.
The prescriber will need to justify why the patient needs more than the plan may initially allow. Ultimately, the doctor may have to order a different medication because the originally prescribed medication was not considered medically necessary.
from there, the member only has two options: