Medicare Part D Formulary Prescriptions

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Pharmskills Online - REJECTED - Third Party Insurance Prescriptions

Electronic Rx - eRx #: 56153, Date: October 4, 2026
Billy Joe Bruno
Accolate 20 mg Tablet
Dispense: 60
Sig: 1 po BID for asthma
Prescriber: Harold L. Green
DAW: generic okay

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Electronic Rx - eRx #: 95282, Date: October 4, 2026
Sylvia F. Jones
Fetzima 40 mg Extended-Release Capsule
Dispense: 30
Sig: 1 po QD for major depression
Prescriber: Carolyn Abman
DAW: give generic

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Electronic Rx - eRx #: 93401, Date: October 4, 2026
William P. Jones
Daliresp (Tablet)
Dispense: 30
Sig: 1 po QD for the prevention of COPD exacerbations
Prescriber: Norman Keyes
DAW: give generic

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Electronic Rx - eRx #: 95583, Date: October 4, 2026
Betty L. Moore
Vigamox 0.5% Ophthalmic Solution
Dispense: 5 mL
Sig: 1 gtt OU q2-4H WA x2 days, then QID x5 days for bacterial conjunctivitis
Prescriber: George Platz
DAW: generic okay

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CLICK HERE to view the Medicare Part D plan's drug formulary

INSTRUCTIONS

Pharmacists are confronting many challenges with the Medicare Part D Prescription Drug Benefit. Among the most time consuming are formulary management, prior authorization requirements, step therapy protocols, and tight formularies. Most Medicare beneficiaries will encounter new formulary requirements, so preparation will be key for pharmacists during their patient's transition to Medicare Part D when they will be in the crucial position of interacting between the plan, prescriber, and patient to lessen any delays in drug coverage.

This exercise will test your ability to help patient's identify which medications may need to be adjusted in order to comply with their plan's formulary. Each patient has a prescription which falls into one of three different problem categories: 1) non-optimal tier, 2) drug requiring a PA, and 3) drug requiring step therapy. You must identify the problem associated with each prescription and then give appropriate documentation, as described below.

Problem #1 - Tier Problem

Pharmacists should strive to ensure that their patients are using the most cost-effective drug alternative. The patient's copay amount for a prescriptions depends on the medication's tier. Most plans have five tiers:

Tier 1 - Preferred Generic Tier

The Generic tier is the lowest-cost tier.

Tier 2 - Generic Tier

The Generic tier is a low-cost tier and contains many generic drugs.

Tier 3 - Preferred Brand Tier

This is a middle-cost tier, and includes preferred brand drugs and certain higher-cost generic drugs.

Tier 4 - Non-preferred Tier

This is a higher-cost tier and includes non-preferred brand drugs and certain higher-cost generic drugs.

Tier 5 - Specialty Tier

The specialty tier is the highest-cost tier. A specialty tier drug is a very high cost or unique prescription drug, which may be brand or generic.

Identify prescriptions where the problem is that the prescribed drug is a tier 3-5 drug. This usually means there is a preferred-generic (tier 1) or generic drug (tier 2) alternative. Document a drug alternative that would be in a lower tier and thus save the patient money.

Problem #2 - PA Problem

Prior Authorization (PA) is also known as "pre-certification." Medications restricted by the plans in this way will require the beneficiary's physician to contact the plan to request coverage of the medication. The physician will usually have to provide the plan with documentation for why this medication is needed for the beneficiary. Typical reasons for requesting a PA drug and the required documentation include:

Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure)
- Specify: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)

Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change
- Specify: Anticipated significant adverse clinical outcome

Medical need for different dosage form and/or higher dosage
- Specify: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason

Request for formulary tier exception
- Specify: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome

Identify prescriptions where the problem is that it is a PA drug. Document what is required by the plan before the physician is allowed to prescribe this drug.

Problem #3 - ST Problem

Step therapy (ST) is a variation of prior authorization. With this utilization management technique, the plan requires the physician to use a preferred drug for that condition, before being allowed to use a different drug.

Identify prescriptions where the problem is that it is a ST drug. Document which drugs or drug classes the plan expects the physician to have tried in this patient before prescribing this drug.