A formulary is the list of medications a plan covers, sorted into tiers. Reading one properly takes about fifteen minutes and prevents the most common unpleasant surprise in January.
The four things to note for each medication
Is it on the list at all? If it is not, the plan does not cover it, and you are choosing between an alternative, an exception request, or a different plan.
Which tier? Tiers run roughly from preferred generics at the bottom to speciality drugs at the top, and your share rises as you go up. Covered is not the same as affordable — the tier is where the actual cost lives.
Any restriction? Three come up repeatedly:
- Prior authorisation — the plan will not pay until your prescriber justifies it.
- Step therapy — the plan wants you to try a cheaper drug first. If you already have and it did not work, that history can usually be submitted and the step waived.
- Quantity limits — the plan pays for a set amount in a set period, which is a problem if your dose is above the standard.
Which pharmacy? Plans have preferred pharmacies where your share is lower. In a small town this may decide which plan makes sense, because there may be only one pharmacy you would realistically use.
How to do it in fifteen minutes
Write down every medication with its exact name, strength and frequency. Copy from the bottle rather than from memory — brand and generic sit on different tiers, and a twice-daily and once-daily version of the same drug can differ.
Then, on HealthCare.gov, enter your medications when comparing plans. The comparison shows the annual cost for your actual list, which is the only number that means anything. A plan with a higher premium is frequently the cheaper year for someone taking three medications.
Look at the annual total, not the monthly premium.
When your drug is not covered
Ask your prescriber about a covered alternative. Usually there is one, and usually it is fine.
Request a formulary exception. If no alternative is suitable — because of another condition, another medication, or because you have already tried and failed the alternatives — your prescriber can request an exception. It succeeds more often than people expect, because a first refusal is frequently a paperwork outcome rather than a clinical one.
Note the date of any refusal. Every appeal deadline is counted from it.
The strong version of an exception request says three things: what has been tried, what happened, and why this drug is right now. “Tried the preferred alternative in March, discontinued after two weeks because of X” does more work than a page of general reasoning.
Why costs change in January
Formularies are rewritten for each plan year. A medication can move tiers, gain a restriction, or leave the list, and nobody telephones you about it.
Your plan writes to you before the year begins setting out what is changing. It arrives with a great deal of other post and is easy to file unread. It is worth fifteen minutes.
Separately, what you pay for the same drug can differ across the year depending on where you are against your deductible and out-of-pocket maximum. January puts everyone back at the beginning, which is why the first refill of the year often costs more than the last one of the old year did.
The annual habit
Once a year, take the bottles, check them against the plan you are being auto-renewed into, and check them against the other plans available in your county. Same fifteen minutes, every autumn.
That single habit is the difference between choosing your January and being surprised by it.
Where to get help
HealthCare.gov’s plan comparison takes your medication list and prices it. The Marketplace Call Center is on 1-800-318-2596, TTY 1-855-889-4325, free and open at any hour. Navigators and certified application counselors help in person at no charge and are not paid by insurance companies — localhelp.healthcare.gov.
If you would rather read the bottles out to someone over the telephone, that is what we do, and we have worked from photographs of them many times.
General information, not advice
This guide describes how Marketplace coverage generally works. It is not advice about your situation, and rules and figures change — verify anything that matters to a decision against HealthCare.gov or the Marketplace Call Center on 1-800-318-2596 (TTY 1-855-889-4325), both free.
Heartland Coverage Partners LLC is not the Health Insurance Marketplace, not HealthCare.gov, and not connected with or endorsed by the United States government. We do not offer every plan available in your area.
