Staying Fit
Despite the central role of formularies in drug access, many older adults have a limited understanding of their health plan’s drug formulary and how its design can affect their ability to get their prescription drugs. At its core, a formulary is a list of prescription drugs covered by a plan. The list contains all the brand and generic drugs that a consumer would have access to as a plan enrollee. In practice, a formulary is a complex, multilayered tool that manages the safe and appropriate use of prescription drugs as well as the interests of a variety of stakeholders.
This fact sheet highlights the essential components of drug formularies and considers the challenges that older adults face when responding to the impacts and implications of formularies annually and throughout the plan year. It notes that low medication literacy—a subset of health literacy defined by a limited ability to obtain information about medication, process it, and use the information to make medication decisions—may further complicate an older adult’s experience with their drug formulary.
This fact sheet includes the following sections:
Formulary Basics
Prescription drug formularies have four common components – covered drugs, utilization management, tiers, cost sharing. Plans create unique formularies by configuring each of these components.
Annual Opportunities to Review Plan Formularies
During open enrollment older adults have an opportunity to evaluate the elements of their plan’s formulary, examine a range of other insurance options, and select a plan with a formulary that meets their needs. Yet the number of available plans may make this formulary comparison difficult.
Day-to-Day Interactions with Formularies
While formularies are designed to help guide appropriate utilization, they can be disruptive for patients. A rejected claim due to formulary constraints can cause a delay in getting the medication, or even cause some older adults to abandon the medication altogether.
Medication Literacy and Drug Formularies
Older adults with low medication literacy may find it additionally challenging to resolve rejected prescriptions, accommodate provider-identified alternatives, compare formularies, or identify a health plan with a formulary that meets their medication needs.
Addressing challenges older adults face, particularly those with low medication literacy, will help improve older adults’ access to the drugs they need. Medicare Part D plans and other insurers, as well as regulators and all parts of the health care system have a role to play.