How should a broker handle a request to substitute a prescribed brand-name drug with a generic due to cost?

• A. Check formulary and coverage, discuss alternatives within the formulary, and document the discussion and decision.
• B. Immediately switch to the generic without any discussion.
• C. Reject the request and keep the brand-name.
• D. Refer to a physician for approval.

Answer: (A)

When a member asks to substitute a prescribed brand-name drug with a generic due to cost, start by verifying that a generic version is on the member’s formulary and that coverage and copays support the switch. Then discuss alternatives that are within the formulary—such as the available generic options or other formulary-approved therapeutically equivalent choices—and make a shared decision with the member. Finally, document the discussion, the rationale for the substitution, and the decision in the member’s record.

This process is best because it balances cost savings with patient access and safety, ensures you’re complying with formulary rules, and creates a clear audit trail. Immediate switching without discussion can undermine patient trust and overlook important therapeutic or coverage considerations. Automatically rejecting the request ignores the opportunity to reduce costs and improve adherence. Requiring physician approval every time can create unnecessary delays unless the plan specifically requires it for that substitution.