When you’re prescribed a new medication, the last thing you expect is that it won’t be covered. Most medicines are covered by health plans. But if you find out a medication isn’t on your plan’s formulary, you have options.
We’ll explain what non‑formulary means, why a medication might be excluded from the formulary and what you can do about it.
Why do health plans use formularies?
Every health plan with prescription drug coverage has a formulary (also known as a covered drug list) that includes medications covered by the plan, plus any rules or limits on that coverage.
A formulary helps:
- Support safe, evidence-based prescribing – Experts evaluate which medications work best and are safest for most people.
- Manage costs – Covered medicines are selected with affordability in mind so you can pay less out of pocket.
- Encourage appropriate alternatives – If there are equally safe and effective generic alternatives to brand-name drugs, those are generally recommended first.
What is a non‑formulary drug?
A non‑formulary drug is a medication that isn’t included on your health plan’s formulary. This usually means:
- There are other medicines that treat the same condition just as well that are covered.
- Your plan has identified safer or more cost‑effective alternatives.
- The medication may have limited evidence or isn’t commonly used for your condition.
Why are some medications excluded from the formulary?
We want our members to have access to the safest, most effective drugs at a price they can manage. Sometimes that means certain medications aren’t included on our formularies. Medicine may be excluded if it:
- Isn’t approved by the Food and Drug Administration (FDA) – We only cover drugs that meet FDA standards for safety and effectiveness.
- Doesn’t have strong evidence showing it works well and is safe – If published research doesn’t clearly support a medication’s benefits, we may not include it.
- Doesn’t provide better results than drugs already available – If an existing medicine works just as well or better for a lower cost, the higher‑priced option may not be added to the formulary.
What’s the difference between a non-formulary drug and an excluded drug?
- Non‑formulary drugs may still be covered by your plan if your doctor requests an exception for a medical reason, such as an allergy or past treatment failure.
- Excluded drugs cannot be covered by your plan under any circumstance, even with an exception or doctor’s request.
How do I know if my medicine isn’t covered (non-formulary)?
If your medicine isn’t on the formulary or you see a “Not Covered” or “NF” (for non-formulary) indicator next to it, your medicine is a non-formulary drug.
Here are a few ways to check if your medicine is covered or is a non-formulary drug (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’s covered and learn about alternatives.
- Check your plan documents – Paper formularies and your plan materials include covered medications and any requirements.
- Call Member Services – They can confirm coverage and help explain your options.
- Ask 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 medication isn’t on the formulary, it either isn’t covered by your insurance or may be covered but cost more than a drug on the formulary. Often, there’s a covered medication that works just as well for your condition. Your doctor can help you review the alternatives that are covered, understand the differences and switch you to a covered alternative if needed.
What should I do if my medicine isn’t on the formulary?
Most prescriptions written for our members are included in the formulary. But if you’ve recently been prescribed a non-formulary drug or changed health plans, you can:
Talk with your doctor about covered alternatives
Talk to your doctor to see if there’s a drug on your plan’s formulary that may work just as well for you as your current medication. It could be a different brand-name drug or a generic. Your doctor can help you explore your options and give you a new prescription if needed.
Request a formulary exception
If alternatives aren’t 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 believes a non-formulary medicine is best for you. It will help reviewers evaluate your request and make a timely decision.
Including as much detail as possible about why your doctor believes a non-formulary medicine is preferred will help reviewers evaluate your request.
Exception requests generally receive a response within one business day:
- If we approve the exception request, we’ll cover your medicine even though it’s not on the formulary.
- If we deny the exception request, you or your doctor can start an appeal by following the instructions in your denial letter. Along with 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 switched plans and my medicine isn’t on the formulary?
Most plans will provide you with a transition refill while you and your doctor review long‑term options. A transition refill, also called a transition fill, is a one-time, 30-day supply of a drug you’ve been taking that your plan doesn’t cover.
If you’re a HealthPartners member that’s eligible for a transition refill, we’ll refill your prescription automatically. And you’ll receive a letter in the mail that explains why your medication was an exception and how to make a switch.
Shouldn’t my doctor know what medicine is best for me?
Your doctor always aims to prescribe the right treatment for you. But new medications, generics and clinical findings are released all the time. This is why health plans have doctors, pharmacists and others whose job is to make sure they know the latest in new innovations and treatments. Most plans also tie their coverage criteria to clinical trial results 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 are getting evidence-based, medically necessary care.
At HealthPartners, formulary decisions are made by the HealthPartners Pharmacy and Therapeutics Committee. This group of doctors, pharmacists and specialists from across HealthPartners and the communities we serve considers direct input from the clinical experiences and comments of our members.
How our clinical review process supports you and your doctor
When developing and maintaining our formularies, the HealthPartners Pharmacy and Therapeutics Committee is guided by a set of principles:
- Proven effectiveness – We look to medicines that are proven to work based on scientific evidence that includes peer-reviewed medical literature, value studies and outcomes research. In assessing this evidence, we consider trial design, case reports and medical opinion. Other considerations for a medicine’s effectiveness include standards of practice, such as treatment protocols and evidence-based practice guidelines.
- Maximized safety – We compare the safety risks and benefits of a drug with other treatments. We also consider qualities like product name, dosage form and packaging that can potentially risk member safety or cause provider error.
- Optimized value – We consider the direct and indirect pharmacoeconomic impacts of a drug or therapy, looking at its overall value compared to existing treatments and its costs as they’re related to medical outcomes. We prefer treatments that make the most efficient use of resources while benefiting the largest potential population.
- Essential for health – How central a drug or treatment is in creating positive health outcomes for members is a major consideration.
- Improved products – We consider whether and to what extent existing drugs and treatments make advances in member convenience, adherence and satisfaction. These can include easier dosing, increased variety of doses, 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 you receive treatments that are safe, effective and reasonably priced.
Can my doctor see my health plan’s formulary?
Yes. Doctors often have access to formularies through health plan portals or other tools. This can help them prescribe covered medicines and avoid delays at the pharmacy. But your doctor may be more comfortable guiding you on the medical aspects of your care rather than your plan coverage.
We recommend confirming coverage with your insurance provider before filling a new prescription, especially for specialized or expensive medications, to avoid any surprises.
Non-formulary drug support for HealthPartners members
If you have a question 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 like:
- Understanding your plan’s pharmacy benefits
- Using your plan’s formulary to look up how a medicine is covered
- Finding effective alternatives for non-formulary drugs
- Getting a prior authorization
- Requesting a formulary exception