Your Health Plan's Formulary:
The List of Preferred Prescription Drugs
Each health plan has its own formulary.
If your health plan covers prescription drugs, it will have a list of the drugs it covers. This list is called a preferred drug list, or formulary. Using your plan’s formulary will help you save money on your drugs.
A group of doctors and other experts choose the drugs on the formulary. The formulary includes common drugs for most health conditions.
Each plan’s formulary is different. However, all the drugs must meet Food and Drug Administration (FDA) safety standards. The FDA is the agency of the U.S. government that regulates drug testing, labeling, and safety.
Some drugs on the formulary may cost more than others.
With some formularies, you pay the same amount for each drug you get. But many formularies have 2 or more cost levels, or tiers. The higher the level, the more the drug costs you.
Generic drugs usually cost less than brand-name drugs. Some brand-name drugs may cost more than others, and some are not on the formulary at all.
Some kinds of drugs are not on the formulary.
- Over-the-counter drugs are usually not on the formulary—unless there is a stronger version that you can get by prescription only.
- Drugs for cosmetic use, sexual problems, or weight loss are usually not on the formulary. Your health plan will not pay for these drugs unless your doctor can show that you need them for medical reasons.
- New drugs may be added. If you need a drug that is new, ask your doctor if it has been added to the formulary.
- A generic version of a drug may replace the brand-name version, or one generic may replace another. When this happens, your co-pay may change or your pills may look different.
- Some drugs may be removed from the formulary, because they are not safe or they do not work well.
Drugs that are on the formulary usually cost less than drugs that are not on the formulary.
- When your doctor writes a new prescription, ask if the drug is on your plan’s formulary and if it is a generic drug. Or ask for the least expensive brand-name drug on the formulary.
- When you fill a prescription, ask the pharmacist if the drug is on your plan’s formulary. If it is not, ask if you can get a drug on the formulary instead. In most cases, the pharmacist can replace a brand-name drug with its generic version. Sometimes the pharmacist will need to call your doctor or health plan.
- Before you change health plans, find out if the drugs you need are on the new plan’s formulary. You can call the plan and ask. Or you may be able to look at the formulary on the plan’s website.
What if a drug I need is not on the formulary or is taken off the formulary?
- Your doctor can ask your health plan to approve the drug. This is called “prior authorization” or “pre-approval.”
- Your health plan should approve or deny your request within a few days.
- If your health plan denies your request, you can file an appeal. Call your plan, or ask your doctor for help. If you have Medicare, call 1-800-MEDICARE and ask what to do.
- Your health plan may say that you have to try a drug on the formulary before you can get another drug. This is called “step therapy.” If the drug on the formulary does not work for you, then your doctor can ask for the more expensive drug.
To view your plan’s formulary:
Call your health plan. Or go to your plan’s website and search for it.
If you have Medicare, find out more about Medicare formularies at:
This series is produced by Consumers Union and Consumer Reports Best Buy Drugs, a public information project supported by grants from the Engelberg Foundation and the National Library of Medicine of the National Institutes of Health. These materials were also made possible by a grant from the State Attorney General Consumer and Prescriber Education Grant Program which is funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin. This brief should not be viewed as a substitute for a consultation with a medical or health professional. It is provided to enhance communication with your doctor, not replace it. Neither the National Library of Medicine nor the National Institutes of Health are responsible for the content or advice herein.