What should a beneficiary examine when evaluating a formulary for known medications?

• A. Check if all current medications are covered, note the drug tiers and cost-sharing, verify required prior authorizations or step therapy, and compare alternatives.
• B. Whether all medications are covered and the cost-sharing structure.
• C. Whether there are required prior authorizations or step therapy, and the availability of alternatives.
• D. The total number of pharmacies in the network.

Answer: (C)

When evaluating a formulary for medications you already take, the most important factor is access barriers and available substitutes within the plan. Knowing that a drug may require prior authorization means your prescriber must provide justification before the plan approves coverage, which can delay or even block you from getting the medication. If step therapy is in place, you might be required to try a less expensive or preferred option first before the medication you’re stable on is covered. These hurdles directly affect whether you can obtain the medicine without surprises or interruptions.

Equally crucial is whether there are viable alternatives within the formulary. If your current medication isn’t preferred or is costly under the plan, having acceptable alternatives ensures you can maintain treatment without breaking the bank or facing denial.

While coverage and cost-sharing matter, they don’t tell you whether access will be blocked by authorization requirements or step therapy, nor do they reveal whether suitable substitutes exist. That’s why focusing on prior authorizations or step therapy and the availability of alternatives provides the clearest picture of how smoothly you can obtain known medications on a given formulary.