Pros And Cons Of Insurance Formularies

Insurance Formulary

Insurance formularies are designed to provide a list of approved drugs in order to lower the costs of certain medications thus preventing patients from having to pay full price. Formularies are often set up in tiers ranging from low-cost, generic drugs to high-cost specialty drugs. Some insurance companies require preauthorization for certain drugs as well as require “step therapy” that includes trying a low-cost drug before authorizing a new or high priced medication. The following paper discusses anticoagulants and prescribing options and dilemmas based on insurance formulary preferences. In conclusion will be a synopsis of how a family nurse practitioner may utilize this information to prescribe in the clinical setting.

Using Formularies

When prescribing medication, the conclusion on which medication should ultimately be decided by both the practitioner and the patient. For instance, as discussed above, Xarelto and Warfarin each have their own pros and cons. If a patient would be more compliant using Xarelto, a FNP can look at that patient’s insurance formulary to see if there will be any restrictions in using Xarelto versus Warfarin. Some formularies such as BlueCross BlueShield has Xarelto listed with dispensing limits (BlueCross and BlueShield of Illinois, 2016). Therefore, it is important for the patient to understand that insurance will only cover a certain number of pills. If the number of covered pills does not cover what they need for an accurate regimen, they will need to pay full price for the rest of the pills. If the patient cannot come to agreement with these terms, then it might be wise to look at the formulary and pick a different option such as