A formulary is a list of the medications your health plan will cover and the rules about covering them. You will pay less for drugs if you stick with your plan's formulary.
Many states have laws that require insurance companies to publish lists of:
- The medications in their formulary
- The procedures for obtaining medications excluded from their formulary
- Both of the items above
Parents should ask whether their plan uses a formulary and request a copy of the formulary list and procedures to obtain coverage for medications that are not included on the list. Your plan’s website might have the list, but double-check with your child’s pediatrician or your pharmacy because networks and pharmacies can change without warning. Ask especially about any drugs your child takes regularly.
If the insurance plan refuses to share its drug formulary, contact your state’s Department of Insurance or other executive branch agency with oversight for health insurance plans. Although it is not an insurance issue, some restrictions (only allowing a 30-day supply for many medications, not allowing telephone call-in prescriptions, etc.) are US Drug Enforcement Administration (DEA) and/or state regulatory issues.
What if the drug your pediatrician prescribes is not on your plan’s formulary?
Your plan is not required to cover all available drugs. If the medication your doctor prescribes is not on the formulary, it is likely that your plan has similar or equivalent drugs available. If your doctor feels these options are not right for you, he or she should seek an exception.
How does the formulary change?
Each health plan company has an established process, such as a committee of physicians and pharmacists who review research on new drugs and make changes to its formulary. Typically, a plan will not make coverage decisions until a new drug has been on the market for at least six months to one year.