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Understanding Health Insurance
Understanding Formularies

Understanding Health Insurance

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Helpful Resources

How to Shop for Insurance

Types of Health Insurance

Understanding Healthcare Costs

How Does the Affordable Care Act (ACA) Affect Me?

Glossary of Healthcare Terms

Forms & Documents Library

Understanding Formularies

Formularies are lists of generic and brand-name prescription drugs and the coverage amount or copay you will need to pay for each prescription. All insurance plans that cover prescription drugs have a formulary, and the formulary includes:

  • Covered medications and the copay linked to each drug. In general, the copays associated with generic drugs will be less than brand-name drugs.

  • Formulary lists are often organized by different levels of coverage or tiers. The first tier might include generic drugs at the lowest cost; the second might include more expensive brand-name drugs; and then the third tier indicates the non-preferred drugs at the highest cost.

  • Medications that require prior authorization from your doctor. This means that your physician needs to provide advance approval before the insurance will cover its portion of the cost for certain drugs.

  • The exact number of pills that can be covered at one time. Often, you can receive a 30-day or 90-day supply of many drugs, but some drugs are prescribed in quantities of only one or two pills. This is often called the Quantity Limit.

Formularies vary by plan, so be sure to check the list associated with your specific plan. Visit the Forms & Documents library to find your plan specific formulary.

Formulary Exceptions

If the drug you have been prescribed is not on our formulary for your specific plan, you may ask us for an exception to our coverage rules. There are several types of exceptions that you can ask us to make. Learn More

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