Drug Formularies and Insurance PDL's

Patient Experience: Drug Formularies and Insurance PDL’s

Relief Is On The Way… Well… Not Quite… Teamwork Time!

So much emphasis has been put on patient education in the last decade. The World Health Organization has created several initiatives to encourage providers and staff to fully educate their patients, and empower patients to learn more and take part in the decision-making process of their own healthcare.  “Engaging patients intelligently in managing their conditions has been shown to improve clinical outcomes” (Barach, et al., 2013).

This includes educating patients on the process of getting their prescriptions and bridging the gap between patient, pharmacist, and insurance companies. I recently interviewed a patient with multiple disabilities that happens to work for an insurance company. The discussion I had with her reminded me of the emotions involved with the “Patient Pain Relief Experience”. Many of us know our patients needs in retrospect, although it is human nature to get caught up in our own daily tasks and go through the motions of our every day. We are human! It happens…

Stories like this are a great reminder of how we are a community and together, we can solve issues faster than just going through our processes and relying on that the process will not fail (this time). I hope this story helps you in some way as for me, it was a good reminder.

In Her Own Words:

This patient had recently moved to a new state and while going through the process of getting a new doctor she found herself doing research for her Fibromyalgia as the pain had been getting worse and more widespread. During her research she came across a few case studies that recommended Lyrica and she could not wait to talk to her new doctor about it.

“This was my last hope at finding pain relief that didn’t include narcotics.”

The day of her doctor’s appointment finally arrived, and her doctor gave her the great news that she was going to prescribe Lyrica and send the prescription to the pharmacy that day! She was ECSTATIC! And then… Sigh… She arrived at the pharmacy and the Pharmacist apologized that the medication is not on the drug formulary, then explained that they would have to fax information to her doctor, she would have to wait although they would call her with an update as soon as possible.

“Initially I was devastated. I held out as long as I could which was not very long, but I broke down in tears out of frustration. All I wanted was relief. I was so excited that this could be the solution that I so desperately needed and now I had to wait, and even then without really thinking about it my emotional reaction was, will I even be able to get this prescription filled.”

What we didn’t mention, is that luckily she works for an insurance company and knows the Authorization process.

“I had to check my emotions and remind myself that I knew this process well… I composed myself and took it upon myself to immediately call my doctor’s office and request they submit a Prior Authorization to my insurance. I knew if the doctor sent it that day, I could have my medication within 72 hours. Working for an insurance company, I speak with patients every day that struggle to get their medications filled due to Drug Formulary and Authorization constraints. Many of the patients I talk to have no idea that Drug Formularies and Insurance PDL’s exist. I can hear it in their voice, they are defeated! Many of them go to chain pharmacies which unfortunately do not have or make the time to go above and beyond and educate their patients on what they can do to expedite this process so they call us for answers. If the patients just understood the process and contacted their doctor right away, the turnaround time for getting their prescriptions filled would be drastically reduced.”

Educated Patients are Empowered Patients:

Because she was educated on the approval process and she communicated with her pharmacist and her doctor on the spot, she felt empowered in a situation that most feel they have no control. She was able to pick up her prescription the next day when the Authorization was approved. The takeaway from this story is to please take the time to educate your staff on the insurance processes, and encourage them to take the time to educate your patients. Patients can help expedite the process. It can really make a difference in your patients’ lives and help reduce the anxiety of the unknown. Many times they put partial blame on the Pharmacy due to not fully understanding the process. Do not let them walk away thinking you had a hand to do with them not getting immediate relief.

When a patient feels (even somewhat) in control of their own destiny, they don’t feel helpless in the process. Even when the outcome is not a desired one, they feel they had a hand in the process and they understand it better versus leaving open to their own perception which can vary from patient to patient. This alone leads to a happier and healthier patient. What is important is that they feel that you care about their immediate relief to the extent that you will “almost” give them a little bit of “insider information” to get faster results. They will remember you, speak about you to others, and you earn the trust of your community one patient at a time. This reminds me of one of my favorite quotes…

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” ― Maya Angelou


Barach, P., Bettinger, J., Charpak, Y., Delnoji, D., Hafner, V., Kutaj-Wasikowska, H., et al.. (2013). Exploring Patient Participation in Reducing Health-Care-Related Safety Risks. Copenhagen, Denmark: World Health Organization, Europe.


2 replies
  1. Rx Guru
    Rx Guru says:

    Ben thank you for the question. Sorry for the delay in our response as I had to reach out to our point of contact to get a direct answer.
    Question: Why was Lyrica not on the formulary in the first place?
    Answer: Lyrica was not on the formulary because the PBM followed its 3-step process and determined there were therapeutic equivalents. The patient had already tried the equivalents. (http://www.mass.gov/anf/employee-insurance-and-retirement-benefits/manage-your-health/prescription-drugs/drug-formularies-are-determined-through.html).

  2. Ben
    Ben says:

    Why was Lyrica not on the formulary in the first place? This article is vague. This person luckily, or by design, worked for an insurance. Not the typical patient. “Do not let them walk away thinking… ‘– Yes, the patient will have to figure out who is really in control of their demise. That is the only way correct change will come for pharmacy and the patient. If we keep standing on our heels and make unpaid concessions then we are enabling the insurance companies. Compliments to the Lobbyists.


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