Formulary Management & Drug Selection Flashcards

A P&T committee is comparing two statins for formulary placement. Drug A has a lower AWP but no outcomes data; Drug B costs more but has proven cardiovascular mortality reduction. What is the best formulary decision?

Answer: Place Drug B preferred because of superior outcomes evidence

P&T committees should weight proven clinical outcomes over acquisition cost alone, favoring Drug B for its demonstrated mortality benefit.

Which federal program requires that drug manufacturers pay rebates to state Medicaid programs as a condition of Medicaid coverage?

Answer: The Medicaid Drug Rebate Program (MDRP)

The MDRP requires drug manufacturers to enter rebate agreements with CMS in exchange for having their drugs covered by Medicaid.

What is the clinical significance of a drug's 'therapeutic index' when making formulary decisions for narrow therapeutic index (NTI) drugs?

Answer: NTI drugs require careful monitoring because small dose changes can cause toxicity or treatment failure

NTI drugs like warfarin, levothyroxine, and lithium have narrow ranges where efficacy and toxicity intersect, requiring careful management when switching products.

A pharmacy benefit manager (PBM) negotiates manufacturer rebates. How do rebates typically influence formulary tier placement?

Answer: Drugs offering larger rebates may receive preferred tier status, lowering member cost-sharing

PBMs often grant preferred tier placement to drugs whose manufacturers offer larger rebates, which can reduce net plan costs despite higher list prices.

An MTM pharmacist identifies that a Medicare Part D beneficiary is in the coverage gap ('donut hole'). How does formulary selection affect their out-of-pocket costs during this phase?

Answer: Generic drugs still have lower cost-sharing than brands in the gap, making formulary generics more advantageous

In the coverage gap, beneficiaries pay a percentage of the drug cost, so lower-cost generics on the formulary result in lower absolute out-of-pocket payments.

What role does pharmacoeconomic analysis play in formulary management?

Answer: It evaluates the cost-effectiveness of drugs relative to clinical outcomes to inform resource allocation

Pharmacoeconomic analyses such as cost-effectiveness and cost-utility analyses help P&T committees weigh drug value relative to clinical benefit when allocating formulary resources.

Which of the following best describes a 'quantity limit' as a formulary management tool?

Answer: Limits the dispensed quantity of a drug to amounts consistent with approved dosing or safety guidelines

Quantity limits restrict drug supply to approved dosing regimens, preventing stockpiling and ensuring utilization aligns with clinical guidelines.