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Formulary Exclusion Criteria

Meaning

Formulary exclusion criteria represent the specific medical, logistical, or financial conditions that must be met for a particular medication or therapeutic agent to be intentionally omitted or removed from a managed care organization’s list of covered drugs, known as the formulary. These criteria are established by Pharmacy and Therapeutics committees to promote cost-effective and evidence-based prescribing within a health plan. Understanding these criteria is critical for patients and clinicians navigating insurance coverage for hormonal therapies or other specialized treatments. Exclusions often prioritize generic or less expensive alternatives when clinical equivalence is demonstrated.