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What’s a formulary and how do they work?
Posted: October 13, 2021
Last updated date: December 01, 2022
Simply put, a formulary is just another name for a drug list. A formulary is the list of generic and brand-name prescription drugs covered by a specific health insurance plan. Sometimes, health plan formularies are also referred to as preferred drug lists (PDLs).
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What’s the purpose of a formulary?
The purpose of a drug formulary is to help manage which drugs care providers can prescribe and that would be covered by a health plan in 2023. The goal of a medical formulary is to make sure that the drugs covered by a health plan are safe, effective and available at a reasonable cost.
Who creates a drug formulary?
Health plan formularies are typically created by a committee set up by the plan’s health insurance company. The formulary committee would likely include pharmacists and doctors from various medical areas. This committee would then choose which prescription drugs to include on the health plan formulary. A health plan may change its formulary drug list from time to time. That may be because new drugs become available, changes in treatment or based on new medical information.
If a prescription isn’t on your health plan’s formulary, you’d probably have to pay for it out of pocket
Medicare drug plan formularies
Certain drugs may be covered under Medicare Part B (medical insurance). But for the most part, Medicare Part B drugs aren’t drugs you'd usually give to yourself. Typically, Medicare Part B drugs are those you’d be given in a doctor's office or hospital outpatient setting.
Medicare Part D drug plans and Medicare Advantage (Part C) plans will have a medical formulary listing the drugs each plan covers. Generally, formularies include a choice of at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. Learn more about the 4 different parts of Medicare.
Dual-eligible health plan drug formularies
Dual-eligible health plans, also known as Dual Special Needs Plans (D-SNPs), are a type of Medicare Advantage plan for people who qualify for both Medicaid and Medicare. Dual health plans may tailor their drug formularies, benefits and provider choices to meet the specific needs of the members they serve.
People on Medicaid and Medicare tend to have serious, long-lasting health problems. They may also be on a number of prescription medicines. Certain prescriptions may not be on the list of Medicaid-approved drugs, drugs approved by Medicare or your health plan formulary. These prescriptions are considered non-formulary drugs.
If a prescription isn’t on your health plan’s formulary, you’d probably have to pay for it out of pocket. And paying for prescription drugs can be very expensive. That’s why it’s important to make sure any prescription medicines you need are listed on the drug formulary before you enroll or switch to a different health care plan.
How to check to see if a formulary includes a drug you need
If you’re looking at a dual health plan or a Medicaid plan offered by UnitedHealthcare, it’s easy to see if a drug you need is listed in the plan’s formulary. Here’s how to view a drug list in English or Spanish:
- Enter your ZIP code in the box at the bottom of this page to find a plan in your area
- Click the “View plan details” button under the plan that interests you
- Select the “Drug list” in the blue provider search box to see prescriptions covered by that plan
Most likely, you’ll want to find out details about drugs you’re taking now. That’s easy to do, because you can look up an alphabetical list of any drug you’re interested in.
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