- A formulary lists the drugs a plan covers and often groups them into cost tiers.
- Prior authorisation means the plan must approve a drug before covering it.
- Step therapy may require trying a lower-cost option first.
- You can usually request an exception if a covered drug is not right for you.
What a formulary is
HealthCare.gov describes a formulary as a list of prescription drugs covered by a prescription drug plan or insurance plan offering prescription drug benefits.
Tiers
Many plans group drugs into tiers. Lower tiers usually include generics with lower cost-sharing; higher tiers may include brand-name or specialty drugs with higher cost-sharing.
Prior authorisation and step therapy
Some drugs need approval from the plan before they are covered. Step therapy rules may require trying another drug first. Your prescriber can help with the paperwork.
Asking for an exception
If a medicine you need is not covered, you or your prescriber can usually ask the plan for an exception. Check your plan documents for the process.
Where do I find my plan's formulary?
It is usually on your insurer's website or in your plan documents. You can also call the number on your insurance card.
Sources
- Formulary (glossary) — HealthCare.gov