MTM Formulary Management & Drug Selection 2 — Questions and Answers
Question 1: Which tier on a typical commercial formulary generally requires the highest patient cost-sharing?
- Generic drugs
- Preferred brand drugs
- Non-preferred brand drugs
- Specialty drugs (Correct answer)
Correct answer: Specialty drugs
Specialty drugs, often on Tier 4 or 5, carry the highest cost-sharing due to their complex manufacturing and high acquisition costs.
Question 2: A Pharmacy and Therapeutics (P&T) committee is reviewing two drugs in the same class with equivalent efficacy but different safety profiles. What should be the primary driver of the formulary decision?
- Manufacturer rebate size
- The drug with the superior safety profile (Correct answer)
- Whichever drug is already on the formulary
- The drug with the lowest acquisition cost
Correct answer: The drug with the superior safety profile
P&T committees must prioritize clinical evidence, including safety, over financial considerations when evaluating formulary placement.
Question 3: What is the purpose of a 'step therapy' requirement on a formulary?
- To allow patients to skip directly to specialty agents
- To require use of a first-line agent before a more costly alternative is covered (Correct answer)
- To eliminate the need for prior authorization
- To mandate generic substitution at the point of sale
Correct answer: To require use of a first-line agent before a more costly alternative is covered
Step therapy protocols require patients to try and fail preferred (usually lower-cost) therapies before coverage is extended to higher-cost alternatives.
Question 4: Which metric best evaluates the clinical appropriateness of a formulary drug selection for a specific patient population?
- Average wholesale price (AWP)
- Drug utilization review (DUR) data (Correct answer)
- Manufacturer sales volume
- FDA approval date
Correct answer: Drug utilization review (DUR) data
DUR data identifies prescribing patterns, inappropriate use, and outcomes, making it the best tool for evaluating clinical appropriateness across a population.
Question 5: A MTM pharmacist notices a patient is using a non-formulary proton pump inhibitor (PPI) when an equivalent formulary PPI is available. What is the best next action?
- Immediately switch the patient's medication without consulting the prescriber
- Document the issue and take no action until the prescriber calls
- Recommend the formulary-equivalent PPI to the prescriber as a cost-saving opportunity (Correct answer)
- Advise the patient to pay out-of-pocket for the non-formulary drug
Correct answer: Recommend the formulary-equivalent PPI to the prescriber as a cost-saving opportunity
MTM pharmacists should collaborate with prescribers to suggest clinically equivalent formulary alternatives to optimize cost without compromising care.
Question 6: Which type of formulary gives plan members the greatest flexibility in accessing non-formulary medications?
- Closed formulary
- Incentive-based formulary
- Open formulary (Correct answer)
- Tiered network formulary
Correct answer: Open formulary
An open formulary covers both formulary and non-formulary drugs, typically with higher cost-sharing for non-formulary selections.
Question 7: Which of the following is a common criterion used by P&T committees when evaluating a new drug for formulary inclusion?
- The drug's brand recognition among patients
- Evidence from randomized controlled trials (RCTs) and systematic reviews (Correct answer)
- Number of television advertisements funded by the manufacturer
- Sales rep familiarity with committee members
Correct answer: Evidence from randomized controlled trials (RCTs) and systematic reviews
P&T committees rely on peer-reviewed clinical evidence, especially RCTs and meta-analyses, to make unbiased formulary decisions.
MTM Formulary Management & Drug Selection 2
Which tier on a typical commercial formulary generally requires the highest patient cost-sharing?