Handle non-formulary drug requests with care

Use this Q&A to guide patient discussions

Brand-name identity in the pharmaceutical industry has hit the ground running, and its timing couldn't be more challenging to a practice with a heavy managed care population. The reason: Most managed care contracts require participating physicians to prescribe drugs only on the MCO's formulary.

So how do you handle patient requests for brand-specific prescription drugs, especially if the requested item isn't on the formulary used by that patient's insurer? The Q&A below can serve as a guideline.

Question: Why might a particular drug not be covered by my health insurance?

Answer: There can be a host of reasons:

· In some cases, there is disagreement as to whether a particular drug is experimental or not. Sometimes coverage decisions for controversial drugs are made by outside panels of experts. Also, consumer pressure can make a difference, too.

· Employers - both public and private - work out specifics of coverage with insurers. Large employers who are "self-insured" are covered by ERISA, the Employee Retirement Income Security Act of 1974. Under ERISA, benefits are determined entirely by the employer.

· Drug formularies, which are a list of covered drugs, can favor one brand or another for a variety of reasons. In some cases, the HMO has cut a deal that gives it good prices for a particular brand over another. Physicians can override the formulary, but physicians also are aware of pressure to contain costs when one brand is as efficacious as another. In most cases, physicians are willing to prescribe a brand if a patient states a particular preference, says Douglas Lee, MD, medical director of Security Health System, the HMO of Marshfield (WI) Clinic.1

Question: What are benefits of drug advertising?

Answer: The increase in advertising can stimulate discussion - among patients, physicians, and insurers, says Lee. Theoretically, drug competition should drive down prices, although that hasn't been the trend in recent years. Increasing patient awareness, however, can keep all health care providers more alert to patient needs and interests.

The best kinds of ads are those that are geared more toward education than selling a product, says Jean Smith, PharmD, director of pharmacy for Scottsdale, AZ-based PCS Health Systems and chairperson of the professional practices committee of the American Academy of Managed Care Pharmacy (AAMCP), an Alexandria, VA-based trade organization of pharmacists.

"Advertising that increases public awareness about certain diseases, informs consumers about available treatment options, and encourages people to pursue healthy lifestyles can improve the health status of patients," an AAMCP position paper states. "Such messages also foster more constructive dialogue between patients and providers."


1. Frieden J. Don't kill the managed care director. Pediatric News 1998; 2:54.