Define: Formulary

A formulary is a list of prescription drugs that are approved for use by a specific health insurance plan or pharmacy benefit manager.

Formularies are typically created by a team of healthcare professionals, including pharmacists and physicians, who review the safety, effectiveness, and cost of different medications.

Yes, formularies can change. Health insurance plans and pharmacy benefit managers may update their formularies periodically to add or remove medications based on factors such as new drug approvals, cost considerations, and therapeutic advances.

If a medication you need is not on your plan’s formulary, you can ask your healthcare provider to request an exception or appeal to have the medication covered. In some cases, you may also have the option to pay for the medication out-of-pocket.

Yes, formularies often categorize medications into different tiers, with lower-tier medications typically having lower copayments or cost-sharing requirements than higher-tier medications.

Yes, you have the right to request a copy of your plan’s formulary. This information is typically available on the plan’s website or by contacting customer service.

Yes, formularies are subject to regulation by federal and state laws, including requirements for transparency, coverage of essential medications, and appeals processes for coverage denials.

Yes, if your health insurance plan denies coverage for a medication on the formulary, you have the right to appeal the decision. This may involve providing additional information from your healthcare provider to support the need for the medication.

Formularies can influence your choice of healthcare provider if certain medications are only covered by specific plans or if your current provider does not participate in the network of the plan with the desired formulary.

Yes, the medications listed on a formulary can impact your out-of-pocket costs, as different medications may have different copayments or cost-sharing requirements based on their tier placement.