Are Non Formulary Drugs Covered by Insurance? Understanding Your Coverage Options

Are non formulary drugs covered by insurance? This is the question that many people ask when they realize that their prescription is not available through their insurance plan’s formulary. If you have ever faced this situation, you know how frustrating and confusing it can be. On one hand, you need the medication to manage your condition, but on the other, you don’t want to pay for it out of pocket. So, what are your options?

The good news is that there is no straightforward answer to this question. It all depends on your insurance plan and the specific circumstances of your prescription. That being said, there are some general guidelines that can help you understand whether or not your non formulary drug might be covered by insurance. In this article, we will explore these guidelines and provide you with some tips and tricks for getting the most out of your insurance coverage. So, if you’re tired of feeling confused and overwhelmed by your prescription costs, keep reading!

Understanding Formulary Drugs

Understanding formulary drugs is crucial to knowing whether or not your medication will be covered by your insurance. A formulary is a list of prescription drugs that are covered by a particular insurance plan and can vary between insurance companies. These lists are created by a committee of healthcare professionals and pharmacists who determine which medications should be included based on factors such as their effectiveness, safety, and cost.

  • Formulary drugs are typically divided into different tiers with different costs associated with each tier. Lower tier drugs will typically have lower copays or coinsurance, making them more affordable for patients.
  • Non-formulary drugs are medications that are not included in the formulary list and may not be covered by insurance or may require a higher copay or coinsurance.
  • Specialty drugs, which are often used to treat complex or chronic conditions, may also require prior authorization or step therapy requirements before they can be covered by insurance.

It’s important to review your insurance plan’s formulary list and understand the different tiers and costs associated with each medication. If your doctor prescribes a medication that is not on the formulary list, they may be able to recommend an alternative medication that is covered or help you through the prior authorization or appeals process to have the medication covered.

What are non-formulary drugs?

Non-formulary drugs are medications that are not on a health insurance plan’s pre-approved list of prescription drugs. These medications may still be necessary for a patient’s treatment plan, but they may require additional steps and costs to obtain.

  • Non-formulary drugs are often more expensive than formulary drugs because they are not covered by insurance.
  • Prior authorization is often required from the insurance company before coverage is approved, which can delay treatment and increase costs.
  • Patients may have to pay a higher co-pay or even the full cost of the non-formulary drug out of pocket.

The table below shows examples of commonly prescribed non-formulary drugs and their average monthly cost without insurance.

Non-formulary Drug Average Monthly Cost (without insurance)
Cymbalta $240
Humira $5,200
Namenda $400
Viagra $370

While non-formulary drugs may seem like a hassle, they are sometimes necessary for a patient’s treatment plan. It is important for patients to discuss their options with their healthcare provider and insurance company to determine the best course of action for obtaining necessary medications.

Insurance coverage for non-formulary drugs

Non-formulary drugs are medications that are not listed on a health insurer’s formulary, which is a list of medications that are approved and covered by the insurance plan. Generally, insurers prefer to cover generic drugs or drugs that are on their formulary list because these drugs are typically less expensive than brand-name drugs.

  • Some insurance plans may cover non-formulary drugs, but generally, they require additional approval from the insurer or doctor.
  • Prior authorization is a process in which a physician must get approval from the insurance company before prescribing a non-formulary drug. The insurer will evaluate the drug’s medical necessity and determine if it is covered by the plan.
  • If a non-formulary drug is not covered by the plan, the patient may have to pay out-of-pocket for the medication or seek alternative options.

It’s important to note that insurance coverage for non-formulary drugs varies by plan, so patients should check with their insurance provider before filling a prescription for a non-formulary drug. Patients can also ask their doctor if a generic or formulary drug would be a suitable alternative to the non-formulary drug they were prescribed.

Below is an example of how different insurance plans may cover a non-formulary drug:

Insurance Plan Coverage for Non-Formulary Drugs
Plan A Prior authorization required, may be covered with a higher copay
Plan B Not covered, patient must pay out-of-pocket for medication or seek alternative options
Plan C May be covered without prior authorization, but may require a higher copay

Patients should always consult with their doctor and insurance provider to determine the best course of action for their individual situation.

Alternatives to Non-Formulary Drugs

When a non-formulary drug is not covered by insurance, patients may feel like they have few options. However, there are several alternatives that can help reduce the cost of their medications.

  • Generic Drugs: These are cheaper versions of brand name drugs that have the same active ingredients. They are typically much less expensive than their brand name counterparts, and they are generally just as effective.
  • Therapeutic Substitution: A therapeutic substitution involves replacing a non-formulary drug with a different drug that has a similar chemical or therapeutic profile. For example, if a specific non-formulary drug is used to treat hypertension, another drug that belongs to the same class (such as ACE inhibitors or calcium channel blockers) may be substituted.
  • Patient Assistance Programs: Many drug manufacturers offer programs that can help cover the cost of medications for patients who are unable to afford them. These programs vary, but they may involve discounts, vouchers, or coupons that can help reduce or eliminate the cost of the medication.

Over-the-Counter (OTC) Medications and Supplements

There are also a number of OTC drugs and supplements that can help address the symptoms or conditions that non-formulary drugs are prescribed for. These may include:

  • Acetaminophen or ibuprofen for pain relief
  • Antacids for acid reflux or heartburn
  • Fiber supplements for constipation
  • Vitamin supplements for conditions like anemia or osteoporosis

Drug Formularies and Coverage Tables

Patients can also consult drug formularies and coverage tables to compare non-formulary drugs with their covered alternatives. A drug formulary is a list of medications that an insurance plan covers, while a coverage table shows the percentage of covered medications in different categories (such as brand name vs generic). These resources can help patients determine the most cost-effective option for their needs.

Drug Name Formulary Status Coverage Details
Brand Name Drug X Non-Formulary Not covered
Generic Drug Y Formulary Covered at 70% co-insurance (patient pays 30% of drug cost)
Therapeutic Substitution Drug Z Formulary Covered at 80% co-insurance (patient pays 20% of drug cost)

By exploring these alternatives and resources, patients may be able to find a solution that helps them afford the medication they need.

How to request coverage for non-formulary drugs

If your healthcare provider prescribes a medication that is not listed on your insurance plan’s formulary, you can request for coverage through the following ways:

  • Prior Authorization (PA): Your healthcare provider can obtain authorization from your insurer to have the non-formulary drug covered for you. This process requires providing clinical evidence and documentation that the medication is medically necessary for your condition.
  • Step Therapy Exception: If your insurer has a step therapy policy, meaning you are required to try lower-cost drugs before accessing higher-cost alternatives, your healthcare provider can make a request for the step therapy exception. This means that you are allowed to skip the lower-cost medication and start with the non-formulary drug immediately.
  • Formulary Exception: Your healthcare provider can request a formulary exception if they believe that the listed formulary drugs are unsuitable for your condition or that the non-formulary drug is more medically appropriate.

After submitting the request, the insurer will review it and provide you with a decision within a specified time frame. You can follow up with your healthcare provider or directly with your insurer for updates.

It’s important to note that not all non-formulary drugs will be granted coverage, and you may be required to pay out of pocket for the medication. Additionally, it’s essential to review your insurance plan’s formulary of covered drugs before selecting a plan to ensure that it includes the drugs you need.

The cost of non-formulary drugs without insurance coverage

Non-formulary drugs refer to medications that are not included on the insurance plan’s list of covered drugs. In most cases, insurer does not cover non-formulary drugs which leaves the member to bear the full cost of the medication. The cost of non-formulary medication can be prohibitively expensive and can quickly add up, leaving many people struggling to afford life-saving medication.

  • The cost of non-formulary drugs is often significantly higher than formulary drugs.
  • Without insurance coverage, non-formulary drugs can be unaffordable for many people, especially those with chronic conditions that require ongoing medication.
  • The price of non-formulary drugs can vary widely depending on the drug, the dosage, and the location where it is purchased.

According to a study by the Kaiser Family Foundation, the average cost of a non-formulary drug is more than four times the cost of a formulary drug. For instance, the cost of a generic formulary drug for treating high blood pressure might only be $10 per month, while the non-formulary version could cost more than $40 per month.

In some cases, non-formulary drugs can cost up to hundreds or even thousands of dollars per month. For example, certain cancer treatments may not be covered by insurance and can cost tens of thousands of dollars per month out of pocket.

Cost of Non-Formulary Drugs Compared to Formulary Drugs Average Monthly Cost
Brand Non-Formulary Drugs $239
Generic Non-Formulary Drugs $81
Brand Formulary Drugs $57
Generic Formulary Drugs $19

It’s clear that the cost of non-formulary drugs can be a major burden for patients without insurance coverage. In some cases, people may be forced to choose between paying for their medication and paying for other essential expenses like rent and groceries.

Challenges faced by patients who need non-formulary drugs

Non-formulary drugs are medications that are not covered by an insurance provider’s drug formulary. While these medications may be necessary for some patients, they often face several challenges in acquiring the drugs they need.

  • Higher out-of-pocket costs: When a medication is not covered by insurance, patients may have to pay out-of-pocket for the entire cost of the medication. These costs can quickly add up and become unaffordable for patients.
  • Approval process: Some insurance providers may have an approval process in place for non-formulary drugs. This process may include a prior authorization request from the prescribing physician, which can delay the patient getting the medication they need.
  • Switching medications: In some cases, insurance providers may require patients to try and fail on other medications before approving coverage for a non-formulary drug. This process can prolong the patient’s suffering and delay the necessary treatment.

Prior authorization forms and paperwork can take a toll on the patient’s mental, emotional, and physical stress. The use of non-formulary drugs can put a significant financial burden on families as well. It’s important for patients to talk to their doctors about any financial concerns or issues while undergoing treatment.

Strategies for patients who need non-formulary drugs

While the challenges faced by patients needing non-formulary drugs can make the journey more difficult, some strategies can help alleviate the burden they face:

  • Appealing rejection: In some cases, if a drug is rejected, some insurance providers allow patients to file an appeal to receive the medication they need. Patients can work with their prescribing doctor to initiate the appeal process.
  • Financial assistance programs: Pharmacy affordability programs offer financial assistance to help patients with the cost of medication. Patients can inquire from the manufacturer or pharmacy they are working with to explore such programs.
  • Alternative medications: In some cases, alternative medicines may be available and more affordable. Your doctor may work with you to identify a less expensive alternative or switch to a medication included in your insurer’s formulary.

The use of non-formulary drugs can be an added burden to patients already going through a difficult time. However, by exploring alternative options, working with their medical providers, and researching financial assistance programs, patients can increase their chances of receiving the medication they need.


Challenges faced by patients needing non-formulary drugs vary from higher out-of-pocket costs to lengthy pharmacy approval processes. However, patients can use strategies such as appealing a drug rejection, inquiring about financial assistance programs or alternative medications to reduce their burden and acquire the medication they need. Seeking help from a financial assistant or even crowdfunding can also help families to afford the drugs necessary for the treatment. It is crucial for healthcare systems, insurance regulators, and pharmaceutical industries to consider re-evaluating their policies, guidelines, and recommendations to aid in the provision of world-class healthcare services to patients.

FAQs: Are non-formulary drugs covered by insurance?

Q: What are non-formulary drugs?
A: Non-formulary drugs are medications that are not included in an insurance provider’s approved list of covered medications.

Q: Are non-formulary drugs covered by insurance?
A: It depends on the insurance provider and plan. Some insurance plans may offer coverage for non-formulary drugs, but it typically requires extra effort and approval from the insurance company.

Q: Why aren’t all drugs covered by insurance?
A: Insurance providers have formularies or preferred drug lists to keep costs down. This allows them to negotiate better prices for the medications on their formulary, making these drugs more affordable for patients.

Q: What should I do if my medication is not on my insurance provider’s formulary?
A: Talk to your doctor about alternative medications that are covered by your insurance. If there is no alternative or your doctor strongly feels that the non-formulary drug is necessary, they can submit a request to your insurance company for coverage.

Q: Is there a way to find out if a medication is covered by my insurance?
A: Yes, you can check with your insurance provider for a list of covered medications. Some insurance companies also offer online tools to search for specific medications.

Closing Message

Thank you for reading about non-formulary drugs and insurance coverage. It’s important to understand what medications are covered by your insurance and the steps you can take if your preferred medication is not on the formulary. Remember to always consult with your doctor and insurance provider to find the best medication options for you. We hope you found this information helpful and encourage you to check back later for more informative articles.