{"id":48791,"date":"2022-02-23T09:30:40","date_gmt":"2022-02-23T14:30:40","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=48791"},"modified":"2026-04-08T11:14:54","modified_gmt":"2026-04-08T15:14:54","slug":"what-is-a-formulary","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/what-is-a-formulary\/","title":{"rendered":"How to understand your prescription drug formulary"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">You might have enrolled in a new health insurance plan or are reviewing your current plan after being prescribed a new medication. You might be wondering about what\u2019s covered\u2014especially when it comes to prescription drugs. Fortunately, it doesn\u2019t have to be difficult or confusing to figure out your drug formulary. Here\u2019s what you need to know.<\/span><\/p>\n<h2 id=\"what-is-a-formulary\">What is a formulary?<\/h2>\n<p><span style=\"font-weight: 400;\">A drug formulary is a list of preferred drugs that your <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/how-to-get-health-insurance\/\"><span style=\"font-weight: 400;\">health insurance plan<\/span><\/a><span style=\"font-weight: 400;\"> covers. This list can vary depending on the insurance plan you have. Preferred medications are chosen based on their safety, effectiveness, and cost. Non-preferred medications are not covered under the drug formulary, or they may be more expensive than preferred medications.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Your health insurance plan creates a drug formulary to provide you access to the safest, most effective treatments. That way you can get your medications at a reasonable price and your insurance company can save money too. In order to be included on the drug formulary, a medication generally needs to be:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">FDA-approved\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Proven as safe and effective according to credible, published studies<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Effective at providing better outcomes than other related drugs<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">More cost-effective than other related drugs<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">The formulary includes <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/are-generic-drugs-as-good-as-brand-name-medicines\/\"><span style=\"font-weight: 400;\">generic and brand-name medications<\/span><\/a><span style=\"font-weight: 400;\"> that are grouped according to their drug class. For example, the medication formulary will list preferred blood-pressure, cholesterol, or pain medications. These medications are further grouped into different tiers that determine how much the insurance plan will cover, or whether there will be any coverage at all.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If your medication is not covered, you can work with your healthcare to find an alternative solution. You can also request an exception from your insurance plan.\u00a0<\/span><\/p>\n<h2 id=\"drug-tier-list\">Drug tier list<\/h2>\n<p><span style=\"font-weight: 400;\">Your health insurance plan creates a drug tier list to show drug costs and insurance coverage. Your <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/healthcare-defined-copay\/\"><span style=\"font-weight: 400;\">copay<\/span><\/a><span style=\"font-weight: 400;\"> or <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/healthcare-defined-coinsurance\/\"><span style=\"font-weight: 400;\">coinsurance<\/span><\/a><span style=\"font-weight: 400;\"> payment will depend on the level, or tier, that drug falls into. The higher the drug tier, the higher the cost of the drug.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Some insurance plans have a formulary with three tiers, but most formularies include four or five tiers. Drugs on Tier 1 consist of the cheapest generic medications while drugs on Tier 5 consist of the most expensive, specialty drugs. The placement of drugs on these tiers can depend on the indicated use, strength, and type of drug.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">A four or five drug tier list could like something like this:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tier 1: Low-cost, preferred generics<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tier 2: Non-preferred generics or preferred brand medications\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tier 3: Preferred and non-preferred brand medications, plus higher-cost, non-preferred generics<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tier 4: Non-preferred brand medications and the highest-cost, non-preferred generics\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tier 5: Highest-cost drugs, including specialty drugs\u00a0<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">Newer, experimental drugs are often placed on higher drug tiers. Drugs on the highest tiers may have low-cost, effective alternatives on the lowest tiers and are therefore not preferred. The highest tiers also include specialty drugs that require specific conditions for dispensing.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Your insurance plan will provide you with a range of potential copays according to each tier. Make sure you read over this information to understand your costs. The cost of drugs on Tier 1 could be as low as $0. For high-tier drugs, you may have to pay a coinsurance payment, or a percentage of the drug cost, instead of a copay.\u00a0<\/span><\/p>\n<h2 id=\"who-creates-formularies\">Who creates formularies?<\/h2>\n<p><span style=\"font-weight: 400;\">The <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4218672\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">pharmacy and therapeutics (P&amp;T) committee<\/span><\/a><span style=\"font-weight: 400;\"> puts together the drug formulary for an insurance plan. This committee consists of healthcare providers with different backgrounds and specialties who review the safety and effectiveness of drugs. They typically choose drugs based on published studies and evidence-based guidelines. The P&amp;T committee may also be contracted with a pharmacy benefit manager (PBM) to manage and update the formulary.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The formulary is usually reviewed and updated every year to ensure the most appropriate drugs are included. A new FDA-approved drug may be added while another drug that is deemed unsafe by the FDA may be removed.<\/span><\/p>\n<h2 id=\"where-can-i-find-my-plan-s-formulary\">Where can I find my plan\u2019s formulary?<\/h2>\n<p><span style=\"font-weight: 400;\">You can usually find your plan\u2019s formulary in your benefits and coverage documents. After purchasing an insurance plan, you should receive an information booklet with the formulary. Your plan should also provide you with potential copay\/coinsurance payments based on drug tier. These documents are sometimes located on the plan\u2019s website or app.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you can\u2019t locate it, call your insurance plan directly. A customer representative can help explain your benefits or guide you to where you can find the formulary.<\/span><\/p>\n<h2 id=\"what-are-formulary-restrictions\">What are formulary restrictions?<\/h2>\n<p><span style=\"font-weight: 400;\">Formulary restrictions are set in place to ensure your doctor is prescribing the safest, most cost-effective drug. Restrictions can help prevent the misuse of medications and manage healthcare costs for everyone.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The most common formulary restriction is a prior authorization. If your prescribed drug has potential safety issues, such as a risk of misuse or abuse, or the drug is available as a low-cost alternative in a different tier, your provider will have to submit a prior authorization. In other words, your provider will have to explain to the insurance company why the prescribed drug is medically necessary for you.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Other restrictions include:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Step therapy: <\/b><span style=\"font-weight: 400;\">In order to provide coverage for some drugs, your insurance plan may require that you try other medications first. If those medications don\u2019t work for you, your plan may provide coverage for the higher-cost drug.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Quantity limits:<\/b><span style=\"font-weight: 400;\"> Your plan may provide limits on how much medication you can purchase at a given time. For example, you may only be allowed a 30-day or 90-day supply at a time for certain medications. This helps ensure you\u2019re taking the medication as prescribed.\u00a0<\/span><\/li>\n<\/ul>\n<h2 id=\"what-if-i-m-prescribed-a-non-formulary-drug\">What if I\u2019m prescribed a non-formulary drug?<\/h2>\n<p><span style=\"font-weight: 400;\">Non-formulary drugs can include over-the-counter medicines, experimental drugs, or certain cosmetic or lifestyle medications like <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/obesity-and-health-insurance\/\"><span style=\"font-weight: 400;\">weight-loss drugs<\/span><\/a><span style=\"font-weight: 400;\">. A non-formulary drug is not covered by your insurance plan, and you\u2019ll typically have to pay the full retail price. However, there are exceptions.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Your physician can submit a request to your insurance company to ask for a non-formulary medication to be covered. A team of healthcare providers will then review the request to determine if the drug is medically necessary and effective. They may also determine whether other treatments should be tried first.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If the request is rejected, your provider can submit an appeal with further evidence on why you need the non-formulary medication. If the request is accepted, the medication will be covered, even if it\u2019s not on the formulary.\u00a0<\/span><\/p>\n<h2 id=\"choosing-the-right-health-insurance-plan\">Choosing the right health insurance plan<\/h2>\n<p><span style=\"font-weight: 400;\">It\u2019s recommended that you do your research when choosing the right health insurance plan. The formulary for one plan does not apply to other plans since different plans will have different benefits. You should shop around and check a plan\u2019s formulary to see if it\u2019s right for you.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you are taking medications for several, pre-existing conditions, it\u2019s in your best interest to find a plan that includes these medications as preferred drugs. It\u2019s especially important to review your <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/what-is-medicare\/\"><span style=\"font-weight: 400;\">Medicare formulary<\/span><\/a><span style=\"font-weight: 400;\"> before settling on a <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/medicare-part-d-plans\/\"><span style=\"font-weight: 400;\">Part D plan<\/span><\/a><span style=\"font-weight: 400;\">. If you\u2019re on a fixed income, high prescription costs can become unmanageable quickly. You can save more money if the drug is on a low tier on the formulary.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you take several non-preferred or specialty drugs, your costs could be high with insurance. In some cases, you may want to use other cost-savings options. For example, <\/span><a href=\"https:\/\/www.singlecare.com\/prescription-discount-card\"><span style=\"font-weight: 400;\">a drug discount card from SingleCare<\/span><\/a><span style=\"font-weight: 400;\"> can help you save on the cash price of your medications. Compare the cost of your medication with insurance to the cost with SingleCare. You may find that you save more using a prescription discount card instead of insurance, especially for high-cost drugs.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you have questions about your drug formulary, you should contact your insurance provider for assistance.\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>You might have enrolled in a new health insurance plan or are reviewing your current plan after being prescribed a new medication. You might be wondering about what\u2019s covered\u2014especially when it comes to prescription drugs. Fortunately, it doesn\u2019t have to be difficult or confusing to figure out your drug formulary. Here\u2019s what you need to [&hellip;]<\/p>\n","protected":false},"author":94,"featured_media":48771,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[2],"tags":[3418,608],"coauthors":[8669],"class_list":["post-48791","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-company","tag-generic-drugs","tag-health-insurance","wpautop"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.4 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>What is a formulary? How to save on high-tier drugs<\/title>\n<meta name=\"description\" content=\"A drug formulary is a list of preferred drugs that a health insurance plan covers. 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