What Is a Formulary Brand Drug?

A formulary, also known as a preferred drug list, is a list of the prescription drugs that an insurance plan's drug benefit covers. A formulary drug brand is any generic or name-brand prescription drug that is included on the formulary and is therefore covered as a standard item by the insurance plan. Insurance companies generally cover less, if any, of the cost of non-formulary drugs, so patients who use non-formulary drugs pay relatively higher prices for them.

How are Formulary Drugs Chosen?

Many insurance plans, including Medicare, choose formulary drugs based on their cost, effectiveness and safety records. An insurance company may include a drug on its formulary if it can negotiate a lower price for it from the drug's manufacturer. Relatively new-to-market drugs are less likely to appear on formularies because they tend to be costlier and may also be backed by less scientific evidence of their effectiveness and safety.

Classes of Formulary Drugs

Formularies contain classes of drugs, such as antibiotics and antidepressants. Within each class, a drug plan may list two or more drugs to give the patient and her doctor some choice about which drug to use to treat a particular condition. However, many formularies exclude some of the most commonly used drugs and classes of drugs, including birth control medications and acne treatments.

The Medicare Formulary

The formularies for all of Medicare's prescription drug plans (PDPs) have six classes of drugs in which all or nearly all of the available drugs in the class are covered:
*Anticonvulsants (examples: Depakote, Lamictal), used to treat conditions including seizure disorders, such as epilepsy
*Antidepressants (examples: Prozac, Zoloft), used to treat conditions including mood disorders, such as depression and anxiety
*Antineoplastics (examples: Celecoxib, Taxol), used to treat cancer
*Antipsychotics (examples: Abilify, Risperdal), used to treat psychiatric conditions, such as bipolar disorder and schizophrenia
*Antiretrovirals (examples: Combivir, Epivir), used to treat HIV and AIDS
*Immunosuppressants (examples: Neoral, Sandimmune) used to treat autoimmune conditions, such as organ transplant rejection and lupus

In other classes, at least two drugs in each class are covered.

Drugs Not on Formularies

Many kinds of drugs are generally not covered by insurance companies and will not be listed on a formulary. These include:

*Over-the-counter products
*Products not approved by the Food and Drug Administration (FDA)
*FDA-approved products being used for non-approved uses

Generic drugs are oftentimes not listed on formularies, but they are likely to be covered by your insurance plan. A customer service agent at your insurance company can tell you if a drug is covered.

Tips

When visiting your doctor, bring your insurance plan's formulary with you. When prescribing drugs for you, your doctor may be able to find a drug that's already on your plan.

If you're choosing a new prescription drug plan, ask to see its formulary. Does it include the prescription drugs you already use? If not, does it include generic equivalents? If it includes a drug that you don't recognize for a condition you already have, ask your doctor whether that drug could be a suitable alternative for you.

Do certain conditions, such as high blood pressure, run in your family? Are you at risk for certain conditions because of your job or lifestyle? If so, check whether drugs for that condition are included on your drug plan before you sign on.

References

• Medicare: Prescription Drug Coverage: Things to Consider
• New York State Department of Health: Definitions for Medicare/Medicaid Dual Eligibles and Medicare Part D Information
• A Guide to Medicare Part D Prescription Drug Coverage for People with Developmental Disabilities

Resources

• Medicare Formulary Finder for Prescription Drug Plans