A formulary is your health insurance plan’s official list of covered prescription drugs. It organizes medications into tiers, with lower tiers generally costing you less and higher tiers costing more. Not all drugs are covered — if your medication isn’t on the formulary, you’ll either need to request an exception or pay full price out-of-pocket.
Most formularies use a 3–5 tier structure:
Formularies can change during the year. Your insurer is required to notify you if a drug you’re currently taking is removed from the formulary, but it’s worth checking before each plan year during Open Enrollment to confirm your medications are still covered and at what tier.
If your drug isn’t covered or is placed on a high-cost tier, you can request a formulary exception through your insurer, asking them to cover the drug at a lower tier if a covered alternative isn’t appropriate for your condition.
Look up your plan’s formulary in your insurer’s member portal or drug finder tool (often called a “drug lookup” or “formulary search”). You can also check during Open Enrollment on HealthCare.gov when comparing plans. If you take specific medications, always check the formulary before enrolling — the same drug can be on different tiers across different plans.
Request a formulary exception through your insurer. Your doctor will need to submit documentation explaining why the formulary alternative is not medically appropriate for your condition. If the exception is granted, the drug will be covered at a lower tier. If denied, you can appeal or ask your doctor about alternative medications that are on the formulary.
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