What is a Formulary?

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Your health insurance plan most likely has something called a “formulary”. Do you know what it is, and how it affects your health insurance coverage? 

A formulary is just a list of prescription drugs that your health insurance plan gives you coverage (i.e., helps you pay) for. Your health plan’s formulary will list the names of the drugs, along with how much or what kind of coverage your health plan provides for it.

So, if you’re wondering whether a drug is covered by your health plan, the formulary for your health plan is the place to go. A formulary is usually a very long list, and it’s often searchable on your health plan’s website.

Health plans will often tailor their coverage for different drugs to ensure clinical appropriateness, quality, and cost effectiveness. For some drugs listed on the formulary, your health plan my cover all or part of the cost for you. For other drugs, though, there might be some conditions on that coverage.

We’ll look at some of these conditions below, including:

  • Drug tiers
  • Prior authorization
  • Quantity limit
  • Step therapy
  • Age limitations

Drug tiers

A formulary will often organize drugs into different groups, or “tiers”. These tiers determine how much coverage your health plan will provide for a drug.

Not all health plans have the same number of tiers in their formulary. But they typically have at least three:

  • Generic Drugs – These drugs tend to get the highest level of coverage from health plans. Your health plan may even cover the entire cost for generic drugs.
  • Brand-name Drugs – These drugs typically get less coverage. Often, they’re separated into two further tiers: “preferred” and “non-preferred”. The preferred brand-name drugs usually get more coverage from health plans.
  • Specialty Drugs – These drugs tend to get the least coverage, or have the most conditions placed on them by the health plan. See below for more information about these conditions.

Conditions on coverage

Here are a few of the conditions that health plans often apply:

  • Prior Authorization (PA) – To be covered, your doctor must provide your health plan with information confirming that you need the drug to be healthy.
  • Quantity Limit (QL) – Your health plan will only cover certain dosages of the drug (e.g., 10 mg per day).
  • Step Therapy (ST) – Your health plan will only cover the drug after it’s shown that treating you with other, similar drugs hasn’t worked. For example, before you can be covered for drug C, you must first have taken drugs A and B.
  • Age Limitations (AL) – Your health plan may have limitations on drugs that have certain age limited FDA indications.

Where is the formulary for my Virginia Premier health plan?

If you’re a Virginia Premier member, you can find your plan’s formulary by:

What if I have questions about my Virginia Premier formulary?

If you’re a Virginia Premier member and you have questions about your plan’s formulary, please contact us.

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