Frequently Asked Questions - Pharmacy Benefits
Q. What is a drug formulary?
A. A formulary is a list of medications that are covered by your health plan. Each health plan may limit coverage to such a list as long as it contains drugs from all drug categories such that necessary medications are provided.
Q. What if the drug your doctor prescribes is not on the formulary?
A. Your plan is not required to cover all available drugs. If the medication your doctor prescribes is not on the formulary, it is likely that your plan has similar or equivalent drugs available. If your doctor feels these options are not right for you, he or she should seek an exception.
Q. How do I obtain an exception to the drug formulary?
A. Each health plan company has a process in place to review these requests. An exception may be made to cover drugs outside of the formulary, if the covered medication is:
- not working
- causes an allergic reaction
- interacts with other medications
- or your doctor otherwise shows that the formulary drug will not produce maximum medical benefit.
Most requests are granted or denied within 48 hours. Your doctor should submit the exception request with supporting evidence.
You may appeal any denial of an exception request.
Q. How does the formulary change?
A. Each health plan company has an established process, such as a committee of physicians and pharmacists who review research on new drugs and make changes to its formulary. Typically a plan will not make coverage decisions until a new drug has been on the market for at least six months to one year.
Q. What is the difference between brand and generic medication?
A. Therapeutically there is no difference. A generic drug is considered to be an exact match in active ingredients to the brand name drug. The main difference lies with the manufacturer, the inactive ingredients and the actual size, shape and color of the medication. The Federal Food & Drug Administration closely regulates the equality of all drugs. Generic drugs usually cost less than brand name drugs.
Q. Can my health plan deny coverage for brand name drugs? What other limits can it impose?
A. Your plan can deny coverage for brand names drugs if generic drugs are available. Your plan may also have limits on the quantity of medication dispensed at one time. The typical benefit will allow up to a 30-day supply or one pre-packaged item for one copayment. Many plans offer tiers in which there is a higher copay for brand name drugs vs. generic drugs.
Q. Why won't my plan pay for OTC drugs prescribed by my doctor?
A. Over-the-counter (OTC) medications are not required to be covered even if your doctor wrote out a prescription
Q. My coverage states I can receive up to a 30-day supply for one copayment, yet I only get 28 days of my oral contraceptive. Shouldn't I be able to get 2 more days or pay a lesser copayment?
A. No. In cases where medications are pre-packaged and sealed, it would not be practical for a pharmacist to break up a package to allow your maximum days-supply. Refer to your contract or benefit summary for language to explain this coverage.
For more information, or to file a complaint, contact the MCS at 651-201-5100 or 1 800-657-3916.