What is a formulary?
Short answer
A formulary is your plan's list of covered prescription drugs. It shows which drugs are covered and which cost tier each one is in.
How formularies work
Each health plan has its own drug list. Drugs are usually grouped into tiers:
- Lower tiers often include generic drugs and cost less.
- Higher tiers often include brand-name and specialty drugs and cost more.
Rules you might see
- Prior authorization — your plan must approve the drug before it's covered.
- Step therapy — you may need to try a lower-cost drug first.
- Quantity limits — a cap on how much you can get at a time.
Formularies change
Drugs can be added, removed or moved between tiers, especially at renewal. Always check next year's formulary before your plan renews.
If your drug isn't covered
Ask your doctor about a covered alternative, or ask your plan about an exception request.
Was this helpful?
Related questions
What if my doctor leaves my network?
Insurers and doctors renegotiate their agreements regularly. When an agreement ends, the doctor becomes out-of-network for your plan.
Why Was My Health Insurance Claim Denied
Receiving a notice that your medical provider's request for payment was rejected can be both stressful and confusing. You may wonder, why was my health insurance claim denied when you have been paying your premiums faithfully every month.
Why Do I Need Prior Authorization
Understanding your health insurance coverage can often feel like navigating a complex maze. One of the most common hurdles you might encounter is a requirement known as prior authorization.
Why Is My Prescription Not Covered
Navigating the pharmacy counter can sometimes feel like solving a puzzle with missing pieces. You arrive with your doctor's order, only to be told that your insurance carrier will not pay for the medication.