How to Make Sure Your Insurance is Covering your Meds: Understanding Drug Formularies

How to Make Sure Your Insurance is Covering your Meds: Understanding Drug Formularies

The best way for members of our society to get the most out of their health insurance is by knowing exactly what their insurance offers. One way to do this, specific to medications that are and are not covered by an insurance plan, is to examine the drug formulary. This webinar provides an in-depth explanation on what a drug formulary is, why it is beneficial to everyone with health insurance, how patients access their drug formulary, and how patients can spread knowledge and awareness about drug formularies to others.

The webinar is co-hosted by GHLF’s Medical Advocacy Liaison Daniel Hernandez, MD, and Patient Advocate and Community Outreach Manager, Jessica Boles, MSW, LSW.

Fast Facts from the Webinar

1. Drug formularies make health insurance owners aware of the medications they can access

A drug formulary is a catalog of all the medications that an insured person has access to through their insurance or a division of the insurance called the pharmacy benefit manager (PBM). A drug formulary splits up the presented medications into a brand name and generic drugs and splits the drugs up into different co-pay tiers based on the patients’ insurance benefits. Brand name drugs are listed in all capital letters and generic drugs are listed in all lowercase letters. The different co-pay tiers start at “Tier 0” and continue to “Tier 4.” Tier 0 consists of drugs that have no co-payment and that are mandated by the affordable care act. These drugs consist of vitamin D, over the counter aspirin, folic acid for women of childbearing age, to name a few examples. Tier 1 consists of drugs with the lowest co-payment and each additional tier consists of drugs with a higher co-payment until tier 4, which consists of specialty drugs that treat complex chronic illness. To further inform the patient about the available medications, the formulary also has abbreviations for drugs to specify age limit, quantity limit, step therapy, non-formulary, and prescription and over the counter access for each drug. For a complete list of these terms and their meanings.

2.  Patients gain power over their treatment through increased opportunity for advocacy

The abbreviations in drug formularies give patients a greater understanding of their medication and allow them to make more informed decisions about their access to treatments. The abbreviations in drug formularies are AL (Age Limit), QL (Quantity Limit), PA (Prior Authorization), ST (Step Therapy), NF (Non-formulary), and RX/OTC (Prescription and OTC). The PA abbreviation shows patients that they can contact their physician to issue a prior authorization to get access to a drug. The ST (Step Therapy) abbreviation provided in the formulary, lets patients identify if a drug requires step therapy, and gives them the chance to safely navigate a Fail First scenario. Drug formularies allow patients to take charge of their medications and understand their benefits based on their health insurance. Your doctors’ office is equipped to help you work through these processes, and you are encouraged to ask them for their help.

3. Accessing drug formularies and spreading the word

Patients can access drug formularies by calling the number on the back of their insurance cards and speaking with their insurance company or visiting their insurance website and finding their drug formulary online. Drug formularies are a key to accessing preferred treatments that you and your doctor may deem necessary to take, and more people need to know about the process to obtain them. As patients advocate for better treatments with the help of drug formularies, they also need to spread awareness about drug formularies to others in their community. The fight for access to preferred and affordable treatments continues, but drug formularies give patients a better chance to obtain the best medication for their specific health needs.

Post Webinar Tips

Being Proactive with Your Employer

Each year when an employer considers a new benefit plan, some companies may allow an opportunity to influence your employer’s decision on which plan they chose. If you know which medications that you’ll need covered, and you feel comfortable, reach out to your human resources department and ask if the plans they are considering cover your medications on their formulary. If you find errors listed on your formulary once you receive it, call your company benefits consultant, ask questions, and don’t give up.

Mid-Year Changes

Pay close attention. Rapid formulary changes can impact you, either when your company chooses a new plan or if there are changes made in the middle of your current plan year. This could result in the insurance company no longer covering your medications, requiring a prior authorization when you didn’t require one before, and other extra steps.

By understanding your formularies and means of recourse, the odds are in your favor to get the help you need. To take back the POWER of ensuring your healthcare needs are being met. Use your formulary as a tool to guide you and your determination to advocate for yourself every step of the way. The only states that ban these mid-year changes are NY, MD, CA, TX, IL, CT, IA, MN. If you live in a state that doesn’t have these formulary changes, sign up to the 50-State Network to advocate for the ban in your state.

If you have questions or would like more information about how to get involved, sign up.

The webinar covered:

Locating your insurance formulary

A look inside your formulary

Abbreviations you should know in your insurance formulary

The meaning of drug tiers in your insurance formulary

What to do when your medication is not listed in your insurance formulary

Watch the full webinar here:


Was this article helpful?
Back To Top