What Are Prescription Drug Formularies?

A prescription drug formulary is a list of medications covered by a specific health insurance plan. These lists categorize drugs into tiers, which determine out-of-pocket costs—lower-tier drugs (typically generics) cost less, while higher-tier or specialty medications cost more.

Why do formularies matter?

• Coverage limitations: Some drugs may require prior authorization, step therapy, or quantity limits before they’re approved.
• Cost differences: Generic medications are usually in lower-cost tiers, while brand-name and specialty drugs often come with higher copays or coinsurance.
• Medicare formularies: Medicare Part D and Medicare Advantage plans with drug coverage each have their own formularies, so covered medications and costs may vary between plans.

How Solace can help

A Solace advocate can help you review your plan’s formulary, find lower-cost alternatives, and navigate prior authorization or appeal processes if a needed medication isn’t covered.

What to do next

Need help understanding your prescription coverage or lowering medication costs? Find an advocate today.