Health insurance companies maintain a list of covered prescription medications. This list is called a formulary, and it is an important tool for you and your doctor. It’s the master list of all the generic and brand-name drugs for which plan members receive benefits, and can help members and providers choose medications that will be most cost-effective.
It’s important to note that while all formularies are approved by Medicare, they are not all created the same and can include a variety of different drugs. This leads to the question: Who decides which drugs are on a formulary?
In short, each Part D plan sponsor is responsible for offering its own formulary.
The Independence Blue Cross formulary
At Independence Blue Cross (Independence), a team of clinical pharmacists are responsible for developing our formularies following the rules set forth by Medicare. The team reviews about 9,000 drugs, carefully reviews studies from the U.S. Food & Drug Administration, and consults with prescribers and specialists in our community before making any decisions about which drugs to include.
The formulary is then reviewed by our Pharmacy and Therapeutics committee (P&T), which is made up of doctors and pharmacists from Independence and the community. Per Medicare rules, the P&T committee membership must meet the following requirements:
- P&T committee members must come from various clinical specialties that adequately represent the needs of the plan’s members.
- A majority of the P&T committee members must be practicing physicians, practicing pharmacists, or both. (The Centers for Medicare and Medicaid Services (CMS) defines a practicing physician or pharmacist to be an individual who has an active professional license to practice in the United States or one of its territories and is currently practicing in the U.S. or one of its territories.)
- At least one P&T committee practicing pharmacist and one practicing physician must be an expert in the care of elderly or disabled persons.
Lastly, the formulary is reviewed by Medicare. Medicare compares Independence’s formulary against all other health plans’ formularies to ensure that we are offering a fair and balanced selection of drugs. Medicare will check all the tiers and prior authorization requirements to ensure compliance. The final decision comes from CMS, and we must receive their approval before we can use the formulary.
What if I am prescribed a drug that is not on the formulary?
Independence Medicare members who are prescribed a drug that is not on their plan’s formulary may submit a formulary exception request, or request their prescriber to do so.
This blog was originally published on LinkedIn.