A formulary is an approved medication list often based on clinical review of evidence-based medicine and both nationally and regionally approved medical guidelines. Both group health and workers’ compensation pharmacy benefit managers (PBMs) have been using formularies for decades to control prescription utilization and costs, and reduce misuse and abuse.
Recently, in a continued effort to reduce prescription medication misuse and abuse, as well as costs, interest in the use of closed or state-level workers’ compensation-specific formularies has grown. In fact, several states have already implemented formularies with varying levels of success, while others contemplate their potential. This leaves many wondering whether state-specific and PBM formularies can work together. We say yes.
Allowing state-specific formularies to work in tandem with PBM formularies creates an optimal medication management environment. A state-based formulary can lend strength to the medication management efforts of the PBM, providing justification for requesting a letter of medical necessity or discussing alternative treatments. Meanwhile, a PBM can support a state-specific formulary by making available clinical resources and tools used to screen for unrelated medications, and helping make certain any medications recommended by treatment guidelines are being appropriately prescribed. They also help watch for and manage any potentially harmful drug interactions or duplication in therapy. Additionally, PBMs can provide a checks and balance system to confirm medical necessity of the prescribed medications.
Consequently, state-specific and PBM formularies are not mutually exclusive. Rather, when permitted to work together, they can have a significant, positive influence on the cost and utilization of workers’ compensation pharmacy benefits, achieving better outcomes for everyone.
To learn more about state-based formularies and how they can work well with PBM formularies, click here to read our white paper, “Working Together to Achieve Better Outcomes: How Using State-Specific and PBM Formularies is a Benefit.”
Helios brings the focus of workers’ compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs – the injured person. This comes with a passion and intensity on delivering value beyond just the transactional savings for which we excel. To learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit www.HeliosComp.com.
This is a sponsored post from WorkCompWire marketing partner Helios.