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Home|Insurance Plans|All About Health Insurance|Understanding Formularies

Understanding Formularies

There really is nothing mysterious about “formularies.” Formularies are simply lists of prescription drugs and the coverage level associated with each drug. (You might also look at a formulary as the list of drugs and the level of the copay you need to pay with each.) Every insurance plan that covers prescription drugs has a formulary, and the formulary includes:

  • Covered medications, both generic and brand name. Generally, the copay associated with generic drugs (identical to the brand name drug), is less than the copay associated with the brand name drug. Formularies are often divided into tiers reflecting the level of coverage associated with each drug.
  • Medications that will be covered if prior authorization is approved. Some prescription drugs require your physician to get advanced approval before insurance will cover it. Formularies list the number of pills that can be covered at one time. You can get 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 called a Quantity Limit. (See Formulary Terms for other examples.)

Formularies vary by plan and product lines so be sure to check the formulary associated with your specific plan to get specific coverage information.