In the world of prescription drug insurance, there are medications that are covered by a health plan and some medications that are not covered. The list of drugs that are covered is known as the Prescription Drug Formulary (or “Formulary” for short).
What is a Prescription Drug Formulary?
If you’ve ever visited a pharmacy with a prescription in one hand and your insurance card in the other, only to be told that your medication is not covered by your insurance… but if your doctor is willing to change the prescription to a similar drug used to treat the same condition… you have first-hand experience of a Prescription Drug Formulary.
The formulary is a list of approved medications for which an insurer has agreed to help cover the cost. However, there might be multiple manufacturers of numerous drugs designed to treat the same condition. This is an opportunity for the insurance company to trim costs by only agreeing to cover one drug for each health condition.
For pharmaceutical manufacturers, this can be a very big deal to be included or excluded from an insurer’s formulary list. Accordingly, each health plan generally reviews its coverage list on an annual basis. This helps ensure they continue to get the best possible price-points for the competing medications that are available to treat high-cost health conditions.
For patients, this can mean that, each year, they may discover the drug they had been taking is no longer covered. This may require them to switch to an alternative medication to continue receiving help paying for the medication from their insurance provider.
What If My Drugs Are Excluded?
It may also be worth double-checking the cash-price (i.e., the price without insurance) for your current medication. You can also contact your insurance company for a copy of their current formulary to review with your physician to see if an alternate medication is acceptable, which can lead to additional savings.
Since 1984 we’ve been working with individuals, families and small companies throughout California to provide complete and unbiased information, so you can make an educated decision for your health insurance needs. If you have questions about your coverage, or would like to explore other health plans, I hope you’ll feel free to contact us anytime.
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