What Is A Drug Formulary?

Health insurance plans are complicated, and it can be hard to understand the ins and outs of what each plan has to offer. One of the things that you need to look at when choosing a plan is what coverage it provides for prescription drugs. Prescription drugs are not cheap, and although the ACA requires insurance companies to include them in their plans, they are not always covered in full – in fact, you may be required to pay more than half the cost of some of your prescriptions out of pocket. To know which drugs are covered and how much you will pay for them, you will need to become familiar with a plan’s drug formulary. 

many precription drugs of all shapes and colors in a pile.

What Is A Drug Formulary?

Simply stated, a drug formulary is the prescription drug coverage provided by a healthcare plan. It is a list of generic and brand name prescription drugs that are covered by each health plan. 

In most cases, you will have a copay for medications which may be $5, $10, $30, or more depending on the drug. If you have a really good plan, then some medications will be covered 100%.

If you look at the drug formulary for different plans, you will notice that prescription drug coverage varies widely depending on the health insurance plan you have. Some plans may have a copay of $30 for a specific drug, while with another plan you will have to pay hundreds of dollars for the same drug. Obviously, paying attention to your plan’s drug formulary is very important.

The Different Tiers

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Health insurance plans rank drug costs with a system of tiers. Coverage is divided into 4 tiers, with drugs in Tier 1 costing the least and going up in price from there. Insurance companies use this system to not only make clear which drugs are covered and how much the copay amounts are, but also to show which drugs they prefer you use. The tiers are:

  • Tier 1– This tier includes generic prescription drugs with the lowest cost/copays.
  • Tier 2– Tier 2 includes non-preferred generics and preferred brand-name drugs. These drugs are slightly more expensive than those in Tier 1, and are called “preferred” because insurance companies prefer that people get prescribed these lower-cost medications.
  • Tier 3– This tier includes non-preferred brand-name drugs which are more expensive than drugs in Tiers 1 and 2. 
  • Tier 4– This tier includes the costliest specialty drugs, which are used to treat serious medical conditions. 

Make Sure To Review A Plan’s Formulary

If you have a specific health condition that requires a certain drug, then you will need to review every plan’s formulary. Different insurance companies might list the same drug on different tiers. Or, one company might have a specific drug in Tier 1 on one plan, but in Tier 2 on another plan. Another company might not even list the drug on any of their tiers.  

Researching different formularies may be time consuming, but it will allow you to pick a plan that meets your specific needs. You will not only learn which drugs are on which tiers, but which have different copay amounts, which have quantity limits, and which require you to pay your deductible in full before they are covered. 

As you can see, not going over a plan’s drug formulary can end up costing you a lot of money. The more you review and understand the tiers, then the better equipped you will be to make a decision on what plan is the one for you. 

What If Your Medication Isn’t on The Formulary?

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If your medication is not on your insurance company’s forumarly, there is an “exceptions process” form that you can fill out and submit online or by mail.

Many health plans share their formularies with healthcare providers, while some do not. If your insurance company doesn’t share this information with your provider, then there is a chance your doctor might prescribe you a drug that is not covered. If your medication is not on your insurance company’s forumarly, there is an “exceptions process” form that you can fill out and submit online or by mail.

Through the exceptions process, your insurance company will be  notified that the medication you were prescribed is deemed necessary by your healthcare provider. You can request that the drug be temporarily covered during the review process. If your insurer decides to cover it long term, then it will most likely be on the highest tier, and so will cost a lot of money. If you are denied, then you can appeal the decision. 

In order to avoid confusion, and the possibility of being denied coverage for medication that is necessary to your health, you need to do a lot of research. This is where EZ.Insure can help. Our team of experts are highly knowledgeable, and can compare all health insurance plans within your region in seconds. You will be provided with a personal agent, and they will go over all the plans, their drug tiers, and will help you sign up for a plan. All of these services come at no cost to you. To receive your free quotes, enter your zip code in the bar above, or to speak to an agent, call 888-350-1890. Let us help you find a plan that meets your health and medication needs.

About The Author: Cassandra Love

With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.
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