Drugs Not on the Formulary: Your Options and What to Do

When you are prescribed a new medication, the last thing you expect is for it not to be covered. Most medications are covered by health plans. But if you discover that a drug is not on your plan’s formulary, you have options.

We’ll explain what off-formulary means, why a drug might be excluded from the formulary, and what you can do about it.

Why do health plans use formularies?

Each health plan with prescription drug coverage has a formulary (also known as the formulary) that lists the drugs covered by the plan, plus any rules or limits for that coverage.

A form helps:

Support safe, evidence-based prescribing – Experts evaluate which medications work best and are safest for most people.
Manage costs – Covered drugs are selected based on affordability so you can pay less out of pocket.
Promote appropriate alternatives – If there are equally safe and effective generic alternatives to brand-name medications, they are generally recommended first.

What is a non-formulary drug?

A non-formulary drug is a drug that is not included in your health plan’s formulary. This usually means:

There are other drugs that treat the same condition just as well and are covered.
Your plan has identified safer or more cost-effective alternatives.
The drug may have limited evidence or is not commonly used for your condition.

Why are some drugs excluded from the formulary?

We want our members to have access to the safest, most effective medications at a price they can afford. Sometimes that means certain drugs are not included in our formularies. The medication may be excluded if:

Not approved by the Food and Drug Administration (FDA) – We only cover drugs that meet FDA standards for safety and effectiveness.
It has no solid evidence to show that it works well and is safe. – If published research does not clearly support the benefits of a drug, we may not include it.
It does not provide better results than medications already available. – If an existing drug works just as well or better for a lower cost, the higher-priced option may not be added to the formulary.

What is the difference between a non-formulary drug and an excluded drug?

Non-formulary medications You may still be covered by your plan if your doctor requests an exception for a medical reason, such as an allergy or a failure of a previous treatment.
Excluded medications cannot be covered by your plan under any circumstances, even with an exception or doctor’s request.

How do I know if my drug is not covered (not on the formulary)?

If your drug is not on the formulary or you see a “Not Covered” or “NF” (for non-formulary) indicator next to it, your drug is not on the formulary.

Here are some ways to check if your drug is covered or if it is not on the formulary (not covered):

Use your health plan’s formulary search tools – You can look up your medication on your health plan’s website to see if it is covered and learn about alternatives.
Check your plan documents – Your plan’s printed forms and materials include covered drugs and any requirements.
Call Member Services – They can confirm coverage and explain your options.
Ask at your pharmacy – Pharmacists often see formulary issues when processing a prescription and can point you in the right direction.

What does it mean if my medication is not on the formulary?

If your drug is not on the formulary, your insurance does not cover it or it may be covered but cost more than a formulary drug. Often, there is a covered drug that works just as well for your condition. Your doctor can help you review the covered alternatives, understand the differences, and switch you to a covered alternative if necessary.

What should I do if my medication is not on the formulary?

Most recipes written for our members are included in the form. But if you were recently prescribed a drug that wasn’t on the formulary or changed health plans, you can:

Talk to your doctor about covered alternatives

Talk to your doctor to see if there are any medications on your plan’s formulary that may work as well for you as your current medication. It could be a different brand name drug or a generic drug. Your doctor can help you explore your options and give you a new prescription if necessary.

Request a form exception

If the alternatives are not right for you, you or your doctor can submit a formulary exception request. Be sure to include as much detail as possible explaining why your doctor thinks a drug that is not on the formulary is better for you. It will help reviewers evaluate your application and make a timely decision.

Including as much detail as possible about why your doctor believes a drug that is not on the formulary is preferred will help reviewers evaluate your request.

Exception requests generally receive a response within one business day:

If we approve your exception request, we will cover your drug even if it is not on the formulary.
If we deny your exception request, you or your doctor can start an appeal by following the instructions in your denial letter. Along with the information from the original request, your doctor’s appeal should include additional relevant details that further explain the need for an exception. The appeal will be reviewed and responded to as soon as possible.
Medicare members can also request an appeal themselves by calling Member Services at the number on their member ID.

What if I just changed plans and my drug is not on the formulary?

Most plans will provide you with a transitional refill while you and your doctor review long-term options. A transition refill, also called a transition refill, is a one-time 30-day supply of a drug you have been taking that is not covered by your plan.

If you are a HealthPartners member and eligible for a transition refill, we will automatically refill your prescription. And you will receive a letter in the mail that explains why your drug was an exception and how to make a change.

Shouldn’t my doctor know which medication is best for me?

Your doctor will always try to prescribe the appropriate treatment. But new drugs, generics and clinical findings are published all the time. That’s why health plans have doctors, pharmacists, and others whose job it is to make sure they know the latest in innovations and treatments. Most plans also link their coverage criteria to the results of clinical trials that ensure the treatment is recommended for patients in the member’s situation. They review medical literature, professional society guidelines, and more to ensure members receive medically necessary, evidence-based care.

At HealthPartners, formulary decisions are made by the HealthPartners Pharmacy and Therapeutics Committee. This group of doctors, pharmacists and specialists from HealthPartners and the communities we serve considers direct input from the clinical experiences and feedback of our members.

How our clinical review process supports you and your doctor

In developing and maintaining our formularies, the HealthPartners Pharmacy and Therapeutics Committee is guided by a set of principles:

Proven effectiveness – We look for medications that have proven effective based on scientific evidence that includes peer-reviewed medical literature, value studies, and outcomes research. In evaluating this evidence, we consider trial design, case reports, and medical opinion. Other considerations for a medication’s effectiveness include standards of practice, such as treatment protocols and evidence-based practice guidelines.
Maximized security – We compare the safety risks and benefits of a medication with other treatments. We also consider qualities such as product name, dosage form, and packaging that can potentially put member safety at risk or cause supplier errors.
Optimized value – We consider the direct and indirect pharmacoeconomic impacts of a drug or therapy, analyzing its overall value compared to existing treatments and its costs in relation to medical outcomes. We prefer treatments that make the most efficient use of resources while benefiting the largest potential population.
Essential for health – An important consideration is how central a medication or treatment is to creating positive health outcomes for members.
Improved products – We consider whether and how existing medications and treatments improve member comfort, compliance, and satisfaction. These may include easier dosing, greater dosage variety, better taste, flexible storage requirements, and more.
Long term stability – To provide predictability and continuity for providers and members, we try to keep formulary changes to a minimum. We weigh the potential disruption caused by making a formulary change against the value and benefit the change would bring.

Together, this helps ensure that you receive safe, effective, and reasonably priced treatments.

Can my doctor see my health plan formulary?

Yes. Doctors often have access to the forms through health plan portals or other tools. This can help them prescribe covered medications and avoid delays at the pharmacy. But your doctor may feel more comfortable guiding you about the medical aspects of your care than about your plan’s coverage.

We recommend confirming coverage with your insurance provider before filling a new prescription, especially for specialty or expensive medications, to avoid any surprises.

Non-formulary drug support for HealthPartners members

If you have any questions about the drug coverage that comes with your plan, our Member Services team has answers based on your specific benefits, prescriptions, and location.

They can help with topics such as: