MTM Formulary Management & Drug Selection 3 — Questions and Answers
Question 1: A drug is placed in the 'non-preferred' tier rather than the 'preferred' tier on a formulary. What does this typically mean for a patient?
- The drug is not covered under any circumstance
- The drug requires a prior authorization regardless of tier
- The patient will pay a higher copay or coinsurance (Correct answer)
- The drug is considered investigational
Correct answer: The patient will pay a higher copay or coinsurance
Non-preferred tier placement signals that cost-sharing is higher than for preferred alternatives, incentivizing use of preferred drugs.
Question 2: When conducting a formulary review for diabetes medications, a P&T committee should consider cardiovascular outcomes trial (CVOT) data primarily because:
- All diabetes drugs now require CVOT data for FDA approval
- CVOTs demonstrate A1C reduction better than older studies
- CVOTs provide evidence on cardiovascular safety and benefit beyond glycemic control (Correct answer)
- CVOTs are required before a drug can receive formulary inclusion
Correct answer: CVOTs provide evidence on cardiovascular safety and benefit beyond glycemic control
CVOTs for diabetes medications reveal cardiovascular safety signals and potential protective benefits, which are critical for patient population risk stratification.
Question 3: Which of the following best describes a 'closed formulary'?
- A formulary that accepts any drug with an FDA approval
- A formulary restricted to only listed drugs, with no coverage for non-listed agents (Correct answer)
- A formulary that only includes generic drugs
- A formulary updated once every five years
Correct answer: A formulary restricted to only listed drugs, with no coverage for non-listed agents
A closed formulary restricts coverage exclusively to drugs on the approved list, maximizing cost control but limiting patient choice.
Question 4: What is the primary goal of a formulary exception process?
- To reduce administrative burden on pharmacies
- To allow coverage of non-formulary drugs when medically necessary for individual patients (Correct answer)
- To replace the prior authorization requirement
- To allow patients to appeal their copay amounts
Correct answer: To allow coverage of non-formulary drugs when medically necessary for individual patients
Formulary exceptions provide a mechanism for patients with unique clinical needs to access non-formulary drugs when formulary alternatives are medically inappropriate.
Question 5: In the context of formulary management, what does 'generic substitution' mean?
- Switching a patient from one brand drug to a different brand drug
- Dispensing a generic equivalent for a brand-name drug when legally permissible (Correct answer)
- Requiring patients to use compounded medications instead of brands
- Substituting one drug class for another
Correct answer: Dispensing a generic equivalent for a brand-name drug when legally permissible
Generic substitution replaces a brand-name drug with an AB-rated generic equivalent, maintaining therapeutic equivalence while reducing costs.
Question 6: Which of the following situations would most likely trigger a prior authorization (PA) requirement on a formulary?
- A patient requests a generic drug that is already preferred
- A prescriber orders a high-cost specialty biologic without documented failure of standard therapies (Correct answer)
- A patient refills a chronic disease medication one day early
- A pharmacist verifies a formulary drug is in stock
Correct answer: A prescriber orders a high-cost specialty biologic without documented failure of standard therapies
PA requirements are commonly applied to specialty biologics to ensure appropriate use and require documentation of step therapy failure.
Question 7: A health plan's formulary includes only one ACE inhibitor and one ARB. A patient's prescriber requests a different ARB not on formulary. What formulary management tool most directly applies?
- Drug utilization review
- Therapeutic interchange (Correct answer)
- Generic substitution
- Quantity limit
Correct answer: Therapeutic interchange
Therapeutic interchange allows substitution of a formulary drug in the same class with equivalent efficacy, with prescriber agreement.
MTM Formulary Management & Drug Selection 3
A drug is placed in the 'non-preferred' tier rather than the 'preferred' tier on a formulary.
What does this typically mean for a patient?