Your health plan’s drug formulary is a list of prescription medications. Drugs that are on this list, or formulary, are covered by your health plan so your health insurance will pay for them. Drugs that aren’t on the list aren’t covered by your health plan, so your health insurance won’t pay for them even though your
doctor prescribes them.
Drug Formularies and Tiers of Coverage
Health Insurance drug formularies often have different levels or tiers of coverage that affect how much you’ll pay for a drug. Each drug is assigned to a tier. How much you pay to fill any particular prescription depends on what formulary tier that drug is assigned to.
For example, the bottom tier may be inexpensive, older, generic drugs like penicillin. Your health plan might charge you a low copay, say $15, to fill prescriptions for drugs on the lowest tier of its formulary.
The second tier might be generic newer drugs or older, cheap brand name drugs. Your health plan might charge slightly more, say $30, to fill prescriptions for drugs on the second tier. The third tier could be newer or more costly brand name drugs for which your health plan will charge you a larger copay, perhaps $60.
The top tier of your health plan’s drug formulary may be expensive chemotherapy, injectable, or biologic drugs. These drugs can sometimes cost your health plan tens of thousands of dollars per year. To help offset the great expense of these top-tier drugs, your health plan may charge you a lot more for them. For example, you might have a 30% coinsurance for a top-tier injectable biologic drug. (Learn the difference between copay and coinsurance.) If your top-tier drug costs $1,500 per dose and you have a 30% top-tier coinsurance, you’ll pay $450 per dose for one
of these top-tier drugs.
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