The manager of one state program recommends that it is much easier to loosen tight cost controls than to start loose and have to cut benefits and access to medications later. Well-designed cost controls promote the dispensation of subsidized medications to those elderly persons who need them most, and who could not otherwise reasonably afford them. Cost controls achieve these ends by discouraging the purchase of unnecessary, inappropriate or ineffective medications, and by recovering a modest degree of program revenue from enrollment fees. Poorly designed deductibles and copayments, often meant to discourage the purchase of unnecessary or ineffective medications, are too often likely to discourage the purchase of medications that are effective at preventing or controlling life-threatening disease. The poor and near-poor elderly often lack adequate medical knowledge or sufficient income to make a wise choice in the face of prohibitive copayments.
Strict formularies forbid coverage for non-listed medications.
Some states go further and restrict coverage to a few limited classes of medications. Other formularies are less restrictive. If a doctor prescribes a non-listed medication, he or she is requested, but not compelled, to substitute from the formulary. Strict formularies don't work well unless they are combined with a sufficient level of physician education and cooperation. Strict formularies should not be created or changed without physician participation and a good program to educate and counsel doctors on the best practice in light of the restricted prescription choices.