Medication Formularies: Navigating the Maze. Anoop Agrawal, M.D. Baylor College of Medicine. Why do drug formularies exist?.
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Anoop Agrawal, M.D.
Baylor College of Medicine
Search in Google: ‘texas medicaid drug search’
Downloadable drug listing: is more cumbersome to use, but lists specific requirements that must be met to receive drugs requiring ‘Prior Authorization.’
Typed in ‘loratadine’
If there is a ‘YES’ in either of the last two columns, then the drug requires a call for PRIOR AUTHORIZATION!
This example highlights a medication that is generic and sold over the counter, yet for Medicaid requires a call for approval.
You will see Medicaid patients at BTGH and TCH – so be mindful of your drug selections.
Preferred Drug List is periodically updated. This one page from the most recent update – January 23, 2008. Overall list is 27 pages.
Left side of page lists preferred drugs.
Right side lists drugs requiring Prior Authorization (PA) along with criteria for approval.
Majority of the criteria are simply treatment failure, contraindication or allergy with preferred products.
67 yo woman signs up for Plan X which costs $35/month.
Step 1: she will pays 100% for the first $275 retail cost of her meds.
Step 2: For the next $2,235 worth of retail cost, she will pay 25% or $558.75. The plan will cover the other 75%.
Step 3: “The Donut Hole” – she pays 100% of the next $3,216.25 worth of medications.
Step 4: “Catastrophic Coverage”- all generics will cost $2.25, all brand names will cost $5.60.