Formulary is a list of drugs which are covered by insurance companies. Insurance company has their own formulary (Covered drug list) and it also differs based on the pharmacy plan.
List of Covered Drugs (Formulary) is developed by the insurances pharmacy and therapeutics committee. This drug list is developed in order to make sure that the health care provider prescribes the best and most commonly used drugs to the patient for the safety and quality purpose.
Formulary can be changed throughout the year for the following reasons.
- When existing drugs listed in the drug list is removed from the market. Drug will be removed immediately from the drug list, when Food and Drug Administration’s (FDA) states the drug is not safe.
- New drugs are approved to include in the drug list.
- If the drugs are available over counter without a prescription then it is not included in a formulary.
So it’s compulsory for you to check the drug list at the time of health care services, to ensure that the drugs prescribed from the health care provider is listed and covered by those insurance companies.
What to do if the Drug you are checking is not listed in the Formulary?
If the drug you are checking is not included in the formulary of that particular insurance, then the next step is to call and check that particular insurance company customer service department.
If they say that your drug is not covered, then you can request customer service team to provide the similar drugs that are covered. Once you get the list of alternative covered drugs from the insurance company, the next step is to check the same with healthcare provider and request him to prescribe the alternative covered drug which is listed in the formulary.
Can you request for medical exception to cover your drug that is not on Formulary?
Yes, you can request a medical exception to cover the non-covered drug which is not in formulary with insurance company department. If its medically necessary and insurance company approve, then the drug which is not listed in the formulary will be covered.
Certain drugs have restrictions or quantity limits on drug coverage. So make sure to double check the formulary correctly and get prior approval from the insurance company to cover those restrictions or limited drugs. If you don’t get approval from the insurance for those restricted or limited drugs, then that drugs will not be covered.
Note: Generally, most of the insurances will not approve if the alternative drugs are found in the drug list.
What does Formulary drug tiers means?
Formulary drug tiers provide the information regarding the portion of the amount to be paid from you for that drug usage.
Drugs on a formulary are typically grouped into 4 or 5 tiers:
Drug Tier 1: Preferred Generic Drugs with low cost sharing.
Drug Tier 2: Generic Drugs with medium cost sharing.
Drug Tier 3: Preferred Brand Drugs with high cost sharing.
Drug Tier 4: Non Preferred Brand Drugs with higher cost sharing.
Drug Tier 5: Specialty Drugs with highest cost sharing.