BOARD CERTIFICATION EXAM STUDY GUIDES Lower Extremity Trauma
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Posted on January 13, 2022 by Dr. David Edward Marcinko MBA MEd CMP™
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By Eric Bricker MD
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Why Are Certain Medications Non-Formulary?
What Are Formulary Tiers and Its Rules?
Formularies Have Many Rules AssociatedWith 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.