Formulary
The list of prescription drugs your plan covers, organized into tiers with different cost-sharing.
A formulary is your plan's list of covered prescription drugs. Plans tier drugs by cost-sharing: Tier 1 (generics, lowest copay), Tier 2 (preferred brands), Tier 3 (non-preferred brands), Tier 4 (specialty), Tier 5+ (highest specialty). Drugs not on the formulary are 'non-formulary' and typically require a formulary exception request to be covered. ACA-compliant plans must cover at least one drug in every USP class and category.
Frequently asked questions
What is formulary?
A formulary is your plan's list of covered prescription drugs. Plans tier drugs by cost-sharing: Tier 1 (generics, lowest copay), Tier 2 (preferred brands), Tier 3 (non-preferred brands), Tier 4 (specialty), Tier 5+ (highest specialty). Drugs not on the formulary are 'non-formulary' and typically require a formulary exception request to be covered. ACA-compliant plans must cover at least one drug in every USP class and category.
Is this relevant to a denial appeal?
Non-formulary drugs are appealable via formulary-exception process when medically necessary.
Related terms
- Non-formulary drugA drug not included on your plan's covered drug list. Requires a formulary exception request for cov
- Step therapyA plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
- Prior authorization (PA)Plan approval required BEFORE a service is rendered, otherwise the plan won't pay.
- Specialty tierThe plan's highest-cost drug tier, typically reserved for biologics, oncology drugs, and complex spe
Appeal a denial
Non-formulary drugs are appealable via formulary-exception process when medically necessary.
Get started →Contact: hello@denialhelp.com