Insurance, Formularies and Prior Authorization Explained

Formularies organize plan coverage

Health plans commonly place medicines into formulary tiers and may prefer certain products, pharmacies or quantities. Coverage can change during the year, so verify the current benefit rather than relying on an old estimate.

What prior authorization does

Prior authorization is a coverage process in which the plan requests additional information before paying for a medicine. It is not the same as a prescription and does not replace clinical judgment.

Questions to ask

Ask whether the medicine is covered, whether the pharmacy is in-network, what the expected patient cost is, and whether a quantity limit, step therapy or prior authorization applies.

When professional help matters

Use a pharmacist or prescribing clinician for medicine-specific questions. For a life-threatening reaction or suspected overdose, call 911. This resource is educational and not individualized medical advice.

Frequently asked questions