A prescription drug formulary is probably one of the most ignored portions of a person’s knowledge of their current insurance coverage.
Usually people don’t pay attention to it until they go to fill a new prescription from their doctor and get sticker shock from the price. It is your responsibility to know what medications are included and reasonably priced with your insurance, and you more than likely have never seen your formulary. So, you play “Russian Roulette” with your newly prescribed drugs, holding your breath when the pharmacist is ready to give you the total, or they call you to make sure you were aware of the cost of the medication before you arrive to the pharmacy (a much kinder approach). If a prescribed drug isn’t in your formulary, it can range in price between several hundreds to thousands of dollars. If it is included in your formulary, but is a Tier 4 or higher drug, you could pay up to several hundred dollars a month for just that medication.
What is the definition of a prescription drug formulary? The main function is to specify specific medications that are approved to be prescribed under a certain insurance policy. There are tiered levels with financial incentives for patients to select lower-cost drugs, which in turn saves both them and their insurance company money. The development of a formulary is based on evaluations of efficacy, safety and cost-effectiveness of drugs. Formularies cover at least one drug in each drug class and encourage generic substitutions.
Back to my “real world” experience. This is important stuff, and there is a lot of money at stake if you are complacent or ignorant about being informed. Many times this is the biggest monthly expense medically for my clients and the most important part of my “fact-finding” when I first meet with them. If you have an insurance broker, ask them for a current version of your plan formulary (it’s updated annually every January 1st).
If you don’t have an agent, call customer service for your current insurance and request one. Formularies are so large now, that most likely it will be sent to you in a PDF format, which is great because you can search “key words” in that electronic document. Lastly, if you’re computer savvy, then you should be able to go to the website of your insurance company and download the current formulary without entering anything more than the name of your plan. It’s information that the insurance companies want to be easily accessible and easy for you to find, unfortunately you just didn’t know that was the case, but now you do. So, get busy on your research before you forget, otherwise you may just be “throwing money away”.