View Accessibility page

Health & Wellness

Health insurance explained: What’s a pharmacy formulary?

We demystify the concept of pharmacy formularies, breaking down the intricacies and empowering you to make informed decisions about your healthcare coverage

Welcome to a topic that often seems more complex than deciphering a doctor's handwriting – health insurance and its puzzling component, the pharmacy formulary. In this blog, we'll unravel the mystery behind this essential aspect of your health coverage, breaking down the jargon into clear, understandable terms.

Understanding the Basics:

First things first, what exactly is a pharmacy formulary? Imagine it as a curated list, carefully selecting which prescription medications your health insurance plan will cover. It's like a well-organized menu, but instead of dishes, you're dealing with medicines. The aim? Balancing effectiveness, safety, and cost.

The Lowdown on Coverage Tiers:

Now, let's talk tiers. Pharmacy formularies often come in tiers, each representing a different level of coverage. Tier 1 typically includes generic medications, with the lowest out-of-pocket costs. As you move up the tiers, you'll encounter brand-name drugs and specialty medications, which may come with higher co-pays or coinsurance.

Formulary Changes: Why and How:

You may have noticed that these formularies tend to change – and more frequently than your favorite weather forecast. Why? The pharmaceutical world is ever-evolving. New medications emerge, old ones lose their patent protection, and costs fluctuate. To keep up, health insurance plans tweak their formularies, striving to balance effective treatment with cost management.

Navigating the Formulary Landscape:

Now, here's the real-world application. Stay informed about any changes to your PHP plan's formulary by checking updates on our website or reaching out to PHP customer service. If your prescribed medication faces a formulary change, your healthcare provider can often assist in finding a suitable alternative within your coverage.

Prior Authorizations and Exceptions:

What if your prescribed medication isn't on the formulary? Take a breath; there's a process for that too. Your doctor can request a prior authorization or file for an exception, explaining why the medication is crucial for your treatment. This process ensures you can access the necessary medication, even if it's not part of the standard formulary.

The Bottom Line:

In the intricate realm of health insurance, understanding pharmacy formularies gives you a valuable edge. It empowers you to make informed decisions about your healthcare, ensuring you get the best value for your coverage. So, the next time someone mentions pharmacy formularies, you can confidently navigate this aspect of the health insurance industry like a pro. Stay informed, stay healthy!

PHP members can rest easy knowing PHP has their own in-house, local pharmacy team dedicated to ensuring our members are well taken care of. They are continually updating our formulary to meet our high-standards of quality, customer-focused care.