Frequently Asked Questions

What is a formulary?
A formulary is a list of prescription drugs that a health plan has approved for use by doctors. Health plans that have formularies develop their own unique list of "approved" drugs. Formularies may change at any time.

Health plans may only pay for medications that are on this "approved" list, unless your doctor goes through the health plan's Prior Authorization process.

What if my doctor wants to prescribe a non-formulary medication?
Your doctor may prescribe a prescription drug that is not on your health plan's formulary; in that case you may have to pay the full price for the medication when you pick it up at the pharmacy.

Your doctor may be able to obtain "prior authorization" from the health plan to prescribe a non-formulary drug. This typically requires that your doctor contact the plan either in writing or on the telephone and make the case for a non-formulary drug. This process can be time consuming and if successful, you will have to obtain authorization every 30 days for refills.

Why does my health plan have a formulary?
Health plans use formularies to control the cost of pharmaceutical health care. There are various approaches as to how plans will implement control. Some will use "closed" formularies that restrict which drugs a plan will pay for and which it will not. Others will use "open" formularies but include different co-pay levels. Others will use guidelines and protocols to encourage physicians to prescribe according to a predetermined therapeutic strategy developed by the plan's health professionals. And sometimes a formulary will include a mixture of these approaches.

Formularies differ between health plans and you should compare availability of medications before making a choice of health plan.

What is a generic drug? Is it safe to take it instead of the brand name drug?
A generic drug is a copy of the original drug that is no longer protected by a U.S. patent. It is typically a drug that has been available for more than 10 years. Generic drug manufacturers are allowed to produce these drugs after the patent for the original has expired. Generic drugs are usually (not always) less expensive than brand drugs, since generic manufacturers haven't had to invest in the research and development of the drug when it was brought to market.

Substituting a generic drug for a brand-name drug usually has no adverse effect. For a few, there could be unintended side effects. If you find that you are having a problem with a generic drug, your doctor may switch your prescription to a branded drug at any time. Plans that recommend generic drugs almost always also cover brand name drugs that can be used for the same therapy. Check with your doctor before switching between brand name and generic drugs.

How often is the information updated?
The information on this site is regularly updated to reflect the continuous changes in formularies. The frequency depends upon the number of changes being reported by the managed care organizations. That typically means three or four updates per year.

What is a therapeutic class and subclass?
Therapeutic classes are used to categorize or group the drugs on the formulary. The classes group drugs which are considered similar by the disease they treat or by the effect they have on the body. Therapeutic subclasses further categorize the drugs into smaller groupings.

What is a formulary status?
A formulary "status" is the means used by health plans to distinguish between drugs on the formulary. Your doctor uses these statuses to interpret the recommendations of the P&T Committee. InfoScan has developed a standardized set of statuses as used on this site to insure that the drugs are being classified using the same terminology for all plans. InfoScan's statuses are explained in the About This Data section of the main menu.

What is Prior Authorization?
A health plan may give certain drugs a status of Prior Authorization (PAR) . If your doctor wants to prescribe a PAR drug for you, he or she must follow the plan's procedure before the drug can be dispensed as a covered benefit. In most cases, the procedure includes filling out a request form which is then addressed by the P&T Committee or pharmacy staff responsible for evaluating requests. This process maybe time consuming and if successful, you may have to obtain authorization every 30 days for refills.

How do I compare coverage for a drug between plans?
The easiest way to compare drug coverage between plans is to use the search menu. You can search by brand name or generic name. Click on the drug name. A list of all the plans in the database will appear and provide you with the status of your drug by plan. A key is available which explains the icons.

Does my doctor have these formularies?
Yes. Your health plan sends it's affiliated doctors a copy of their plan formulary. InfoScan sometimes publishes plan formulary books. In California we also publish the Triple i CA Managed Care Formulary Guide which is sent free to approximately 24,000 California physicians. Also, this site can be used by doctors to review drug statuses.

What if my drug is not listed?
There are a number of reasons the drug may have a "not listed" status. You will need to check with your plan for information about that drug or their policy for not listed drugs. You may sometimes find an explanation attached for a not listed drug by clicking on the note icon, if one is located next to the symbol.

How can I find out if my drug is listed?
From the search menu, on the letter of the alphabet that corresponds to the first letter of the drug you are seeking. This will give you a list of drug names to pick from. Scan the list and click the one you are interested in reviewing. The table will display the drug for all the plans in California.

A drug I'm interested in is listed twice. What does that mean?
The drug is in two different therapeutic classes or subclasses. Your drug can be prescribed for more than one disease or condition. You will need to look at the appropriate therapeutic class for your condition to find the status. Statuses can differ between therapeutic classes. For instance, a drug can be preferred in one class and approved in another class.

Are all unlisted drugs reimbursed if there isn't a not reimbursed symbol?
Not necessarily. You will need to check with your health plan to ensure they will reimburse you for a drug not on their formulary. In general, if the drug has a status of "approved" or "preferred", it will be reimbursed. If the drug has a status of "non-formulary" or "prior authorization", it may be reimbursed as usual, at a different rate or not at all.

If my drug is not reimbursed, does that mean I cannot get it?
No. Doctors can prescribe any medication they choose. However, if the drug is not listed on the formulary and you cannot obtain it through the plan's prior authorization process, you may have to pay the total cost of the medication.