Formulary Management & Drug Selection Flashcards

Under Medicare Part D, what is a 'protected class' of drugs and why are these classes significant for formulary management?

Answer: Six drug classes CMS requires Part D plans to cover all or substantially all drugs within

CMS designates six protected classes (e.g., antiretrovirals, antidepressants, antipsychotics) in which Part D plans must offer broad formulary coverage to protect vulnerable patient populations.

When evaluating biosimilars for formulary placement, a P&T committee should consider which of the following as most clinically relevant?

Answer: FDA interchangeability designation and evidence of comparable efficacy and safety to the reference biologic

FDA interchangeability designation means the biosimilar may be substituted for the reference biologic without prescriber intervention, making it highly relevant for formulary substitution policies.

A health plan wants to reduce inappropriate antibiotic prescribing through formulary design. Which formulary management strategy would be most effective?

Answer: Placing narrow-spectrum antibiotics on preferred tiers and requiring step therapy or PA for broad-spectrum agents

Preferring narrow-spectrum agents and requiring documentation for broad-spectrum use stewards antibiotic use without removing necessary treatment options.

In formulary benefit design, what is the difference between 'cost-sharing' and 'cost containment'?

Answer: Cost-sharing shifts drug expenses to members; cost containment reduces total drug expenditure for the plan

Cost-sharing strategies (copays, coinsurance) transfer some drug expense to members, while cost containment strategies (rebates, generics, step therapy) reduce the plan's total drug spend.

A patient's oncologist prescribes a non-formulary chemotherapy agent. The plan's formulary includes an alternative with different toxicity but comparable response rates. What should the MTM pharmacist prioritize?

Answer: Review the individual patient's comorbidities and discuss clinical nuances with the oncologist before any formulary switch

Oncology formulary decisions require individualized clinical review because toxicity profiles may be critical for patients with specific comorbidities or prior treatment histories.

What is the primary purpose of a 'medication formulary exception appeal' process for Medicare Part D beneficiaries?

Answer: To provide access to non-formulary or higher-tier drugs when the standard formulary options are medically inappropriate

The Part D exception and appeals process ensures beneficiaries can access medically necessary drugs not covered by the standard formulary when alternatives are clinically contraindicated.

Which statement best describes the relationship between formulary management and medication adherence in MTM practice?

Answer: High cost-sharing and restrictive formularies can reduce adherence, making formulary optimization a critical MTM target

Research consistently shows that high out-of-pocket costs and step therapy burdens can reduce adherence, so MTM pharmacists target formulary optimization to remove cost barriers.