What is a Formulary?

Blog-Formulary-1250x300

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.

SHARE THIS NEWS
Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn
Share on email
Email
Share on print
Print

Resources

By logging in to this portal, I affirm that I have read, understand and agree to abide by the following terms and conditions: 

I certify I am a health care provider, an employee of a health care provider, a business associate of a health care provider, or an employee of a business associate, and the purpose of my access to any Virginia Premier System is related to the provision or payment of health care services.

With respect to all information viewed or obtained from this site, I agree to comply with all applicable federal and state laws regarding the confidentiality and integrity of health and medical records. This includes full compliance with the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), the HITECH Act, and the Virginia Health Records Privacy Act, and applicable regulations to these laws.

I agree to keep confidential all information related to Virginia Premier System business, including, but not limited to, quality and risk management activities as well as other confidential or personal information concerning the medical, personal, or business affairs of Virginia Premier System and its members.

I agree to notify Virginia Premier System immediately in the event that my network access has been compromised in any way and in the event of unauthorized use or disclosure of any information obtained from the Virginia Premier System network.

Need to register for a new account? Click here.

In order to register for an account, if you would like access to all group NPIs/APIs under a single Tax ID, please enter your Tax ID only. If you would like access to a specific group NPI/API instead, please enter it in the field provided. 

For expedited registration, please provide a Claim number and the Total Billed Charges on the claim when creating your account.

You will receive an email within 3-5 business days with your username and temporary password.

Please call Technical Support for help with Virginia Premier’s Provider Portal at 1-877-814-9909 or email connect@healthtrio.com. 

Virginia Premier is offering EFT services through PaySpan.

Please click here to sign-up

If you have questions or need help please, contact our Provider Services department at vphpnetdev@virginiapremier.com or by calling 804-968-1529.