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 medications 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 and generic drugs. Some plans may also include certain over-the-counter (OTC) medicines. For coverage on a drug plan, most medicines will require a healthcare provider’s prescription.
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 or calling their member help line. Check out your health plan eligibility card for available phone numbers.
Many states have laws that require insurance companies to publish:
The medications in their formulary
The procedures for obtaining medications excluded from their formulary. Getting permission for non-formulary prescriptions will usually require and action by the prescriber.
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 child's pediatrician or pharmacy may be able to help you get the information needed.
Health plan networks and eligible pharmacies can change without warning. Be sure to ask especially about any drugs that your child takes regularly.
What if my insurance plan doesn’t provide its drug formulary?
If the insurance plan refuses to share its drug formulary, contact your state's Department of Insurance or other executive branch agency that 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 U.S. Drug Enforcement Administration (DEA) and/or state regulatory issues.
What if the drug that my child's 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, they may be willing to seek an exception, called "prior authorization," to get approval for specific drug coverage for your child.
How do health insurance formularies change over time?
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. Drug cost relative to its value for patients is also one of the aspects they consider. Typically, a plan will not make coverage decisions on a newly marketed drug until it has been on the market long enough to support its benefit for drug plan recipients.
Why is it that my child's medication was on the insurance formulary last year but was removed this year?
Health insurance companies have drug committees that annually review the drug formulary list. Sometimes 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 U.S. Food and Drug Administration (FDA) may approve novel drugs that work better than older ones. Finally, drugs may be removed from the formulary altogether if they become available without a prescription (over-the-counter), are removed from the market or companies no longer make them.
Can I request that a drug be added to the formulary?
Yes. You can 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, and their drug committee may decide to add the drug to their formulary.
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