HealthCare.gov defines a formulary as, a list of prescription drugs covered by a prescription drug plan offering prescription drug benefits. Typically, a “prior authorization” for coverage is needed when a medication is not listed on the formulary or requires step therapy. Management of the formulary is often maintained by a pharmacy benefit manager (PBM), such as First Script. Meaning, when a medication is not on a formulary, First Script would start the prior authorization process to get approval for payment of the medication. Step therapy is the concept of a patient trying a first-line recommended medication before taking a “step up” to a medication that costs more and/or has less supporting evidence of effectiveness. Typically, a formulary (aka, drug list) shows where a medication is regarding “step” in therapy and what conditions need to be met before the medication is approved for payment. The medications on a drug list and the conditions of step therapy can be determined in several ways. However, The Official Disability Guidelines (ODG) from the Work Loss Data Institute and the Practice Guidelines from the American College of Occupational and Environmental Medicine (ACOEM) are tailored to workers’ compensation. In the case of workers’ comp, many factors may go into step therapy requirements and formulary placement, including work-relatedness, cost of the medication, place in therapy, treatment guidelines, availability of alternative agents, and evidence-based medicine (EBM) resources.
More stories
Enlyte Quarterly Medical Price Index - Q2
As reported by the Bureau of Labor and Statistics (BLS) for April 2024, the
Enlyte Pharmacists Discuss a Changing Workers’ Comp Pharmacy Landscape
Workers' compensation pharmacy is constantly evolving, from tackling the opioid crisis, to the rise of compounding pharmacies, to the pandemic.
Enlyte Pharmacy Experts Speak on Turning Challenges Into Opportunities
Clients face numerous challenges in managing their workers' compensation pharmacy programs including capturing all pharmacy utilization and costs a
Enlyte Experts Discuss the Benefit of a Holistic Approach to Pharmacy
Seizing opportunity within the complexities of workers’ comp prescription utilization requires a holistic approach that manages all transactions to
Enlyte Launches Bundled Solution for Auto Bodily Injury Cost Containment
PrecisionDirect allows auto carriers to improve payment accuracy for provider services SAN DIEGO, Calif—During
Ensuring Precision and Agility in Settlements
Let’s set the stage with some facts that every carrier can relate to: a desire to close claims quicker and with more accuracy.