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Your Health Plan’s Formulary

What is a formulary?

A formulary is a preferred list of medications your health plan will cover and the rules about covering them. The decision to include a specific drug in the formulary is made by the health plan after considering its safety, effectiveness and cost. You will have less out of pocket expenses for drugs if you stick with your plan's formulary.

What types of drugs are included in a formulary?

All types of drugs that are used to prevent and to treat various illnesses are included in the formulary. They can include brand-name drugs and generic drugs.

How do I learn more about my drug formulary?

You can obtain information on the general rules that govern the formulary and the specific drugs that are included in the formulary by accessing them from your insurance company's website.

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

You should ask whether your plan uses a formulary. Request a copy of the formulary list and learn how to obtain coverage for medications that are not included on the formulary. 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 that your child takes regularly.

What should I do if the insurance plan refuses to share its drug formulary with me?

If the insurance plan refuses to share its drug formulary, contact your state's Department of Insurance or other executive branch agency which oversees health insurance plans. Although it is not an insurance issue, some restrictions (such as 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 that my pediatrician prescribes is not on my 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 has an established process, such as a committee of physicians and pharmacists who periodically 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.

Why is it that my drug was on the formulary last year but has been deleted from the formulary this year?

Health Insurance companies have drug committees that annually review the drug formulary list. Sometimes new drugs may be added to the formulary and older ones removed. This happens because some brand-name drugs may lose their patents and more economical generic drugs may become available. In other instances, the FDA may approve new drugs. Finally, drugs may be removed from the formulary altogether if they become available without a prescription (Over-the-counter "OTC" drugs)

Can I request that a drug be added to the Formulary?

Yes. You should ask your physician to write to the insurance company requesting that a specific drug be included in the formulary. It is important that the doctor also send supportive information, such as medical, peer-reviewed studies that demonstrate the drug's effectiveness to the insurance company. The company will review the request.

Additional Information:

Last Updated
American Academy of Pediatrics (Copyright © 2015)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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