In PBM claim adjudication, which step confirms that the prescribed medication is included on the member's formulary?

In PBM claim adjudication, which step confirms that the prescribed medication is included on the member's formulary?

• A. Verify it's on formulary
• B. Verify belongs to member
• C. Price determined
• D. DUR electronically determined

Answer: (A)

Formulary check is the step that determines whether a prescribed drug is covered for the member. During PBM claim adjudication, the system cross-references the drug against the member’s formulary list. If the medication is on the formulary, the claim can proceed with the appropriate coverage level and patient cost. If it isn’t on the formulary, the claim may be denied or routed through an exception or prior authorization process. Other steps serve different purposes: verifying belonging confirms the patient’s eligibility, price determination computes the cost once coverage is established, and DUR checks safety and appropriateness rather than coverage status.

Formulary check is the step that determines whether a prescribed drug is covered for the member. During PBM claim adjudication, the system cross-references the drug against the member’s formulary list. If the medication is on the formulary, the claim can proceed with the appropriate coverage level and patient cost. If it isn’t on the formulary, the claim may be denied or routed through an exception or prior authorization process. Other steps serve different purposes: verifying belonging confirms the patient’s eligibility, price determination computes the cost once coverage is established, and DUR checks safety and appropriateness rather than coverage status.