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Patient Advocate Foundation (PAF) is a national 501 (c)(3) non-profit organization which provides case management services and financial aid to Americans with chronic, life threatening and debilitating illnesses.
Knowing which medications are covered by your health insurance, as well as how they are covered, will go a long way in helping you maximize your benefits and save you money.
What is a Drug Formulary?
A drug formulary is a list of medications covered by your insurance plan separated by tiers that determine their cost.
What do the different tiers mean?
All covered medication fall into one of several tiers. Each tier represents a level of cost that you will pay for that medication. The number of tiers varies by formulary.
What drugs are covered on the drug formulary?
Drug Formularies typically include most Food and Drug Administration approved generic drugs and brand-name drugs.
What are brand-drugs?
A brand-name drug is a new medicine that has been discovered, developed and marketed by a pharmaceutical company. Once a new drug has been discovered a patent is filed on it that prevents a rival company from creating a generic version for up to 20 years.
What are generic drugs?
Generic drugs are identical to brand-name drugs in dosage, safety, strength, quality, performance and intended use. They are sold at substantial discounts compared to their brand-name counterparts.
Do drugs covered on the formulary have any restrictions?
Yes. There are three common restrictions on a drug formulary.
Step therapy: A restriction that requires you to first try an equally safe and effective drug that is cheaper before you are allowed to get a more expensive version.
Prior authorization: A restriction that requires your doctor to obtain authorization from your health insurance provider before you can get your medication.
Quantity Limits: A limit on the amount of a particular drug you can get.
Are all drug formularies the same?
No. Each health insurance provider has its own drug formulary.
Who decides what goes on a drug formulary?
Each health insurance provider uses an independent panel of experts to choose which drugs will go on the formulary. This is known as a pharmacy and therapeutics committee. The committee is made up of pharmacists, physicians and other clinical experts.
Where can I get a copy of my drug formulary?
You can find a copy of your drug formulary on your health provider’s website. You can also call your health provider directly and request that a printed copy of your drug formulary be mailed to you.