Open vs. Closed Medication Formularies in Hospice: Finding the Right Balance

In hospice care, medication access is not just a financial decision—it is a clinical, operational, and ethical one. The way a hospice structures its medication formulary can directly influence patient comfort, clinician satisfaction, workflow efficiency, and total cost of care. At SimsRx, we work closely with hospice organizations across the country, and one theme consistently emerges: the most sustainable pharmacy strategies balance access, autonomy, and accountability.

Industry Insight: What Leaders Are Saying

Recently, our founder conducted a poll of close advisors across the hospice and pharmacy space—clinical leaders, administrators, and operational decision-makers who live these challenges every day. The results were telling:

88% expressed a preference for an open formulary strategy over a closed formulary model.

While preferences alone should never dictate policy, this strong consensus reflects growing frustration with rigid systems that promise cost control but often introduce clinical friction and operational burden.

Understanding the Models

Closed Formularies: Predictability with Tradeoffs

Closed formularies are designed to limit medication options to a predefined list, often with the goal of cost containment and utilization control. In theory, this approach offers:

Pros:

• Predictable drug spend

• Simplified inventory management

• Clear guardrails for prescribing

Cons:

• Increased prior authorizations and rejections

• Delays in symptom control

• Reduced prescriber autonomy

• Workarounds that increase administrative burden

• Clinician dissatisfaction and burnout

In hospice—where responsiveness and individualized care are paramount—these constraints can be especially disruptive.

Open Formularies: Flexibility with Responsibility

An open formulary allows prescribers access to a broad range of medications while relying on clinical oversight rather than restriction alone.

Pros:

• Preserved prescriber autonomy

• Faster access to appropriate therapies

• Fewer prior authorization and rejection encounters

• Improved clinician satisfaction

• Better alignment with patient-centered care

Cons (when poorly managed):

• Risk of cost variability

• Potential for inconsistent prescribing

• Requires strong clinical pharmacy infrastructure

The key distinction is not open versus closed—it is whether the open formulary is supported by high-touch clinical pharmacy expertise.

A Real-World Example: Open Formulary Done Right

One of the hospice organizations we have advised for over a decade illustrates what is possible when an open formulary is paired with intentional clinical integration.

• Average census: ~70 patients

• Formulary model: Open

• Clinical approach: Embedded, high-touch clinical pharmacy services

• All-in pharmacy cost: $8.50 per patient per day, including ancillary services such as delivery and prefilled syringe programs

This hospice has consistently maintained cost discipline—not through restriction—but through clinical optimization embedded directly into their workflows.

What Makes It Work

This success is not accidental. It is the result of deliberate integration of clinical pharmacy services into the hospice’s care model, including:

• Medication de-escalation and deprescribing aligned with goals of care

• Coverage determination and benefit navigation before issues become denials

• Methadone optimization for appropriate patients, improving pain control while managing cost

• Active pharmacist participation in IDT meetings, ensuring real-time collaboration

• Transparent medication decision-making, rather than reactive utilization controls

Critically, prescribers retain autonomy over medication selection. Instead of being blocked by formulary walls, they are supported by pharmacists who act as clinical partners—not gatekeepers.

The Result: Balance Without Compromise

This approach has allowed the hospice to achieve a rare balance:

• Autonomy for clinicians

• Access for patients

• Transparency for leadership

• Predictable, sustainable pharmacy spend

All while delivering exceptional patient care and increasing provider satisfaction by reducing friction, prior authorizations, and rejected claims.

The SimsRx Perspective

At SimsRx, we believe that formularies should serve care—not the other way around. Open formularies, when paired with integrated clinical pharmacy services, can outperform restrictive models on both quality and cost.

The question is no longer whether an organization can afford an open formulary. The real question is whether they can afford the operational drag, clinician dissatisfaction, and patient impact of a closed one.

If your hospice is re-evaluating its pharmacy strategy—or struggling to reconcile access with accountability—we welcome the conversation. The right model already exists. It simply requires the right partnership.

Interested in learning how SimsRx supports open formulary success through clinical integration? Let’s talk.