PODCAST: Fundamentals of Healthcare Finance

Today’s Video is a Fundamental of Healthcare Finance That Every Professional Must Understand… and that Most Consumers DO NOT.


2021 Medical Captive Forum | Roundstone Insurance


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.

Citation: https://www.r2library.com/Resource/Title/0826102549


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.

ASSESSMENT: Your thoughts are appreciated.



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