Inhaler not covered, what is a “drug formulary”?

 I was just diagnosed with asthma and my doctor prescribed an inhaler.  When I went to the pharmacy to get it, I was told that the inhaler was not on my plan’s formulary.  And my doctor would have to choose another one.  What is a formulary?  And since when can my plan tell my doctor what to prescribe?

Getting Huffy

Dear Getting Huffy,

A formulary is a list of drugs that your health plan “prefers”.  Essentially, the manufacturers of these drugs have an agreement with your health insurer on pricing and net costs.  Drugs get on the preferred list via negotiation, which is not the same as being preferred because they are superior.

Your doctor may be able to ask the insurer to allow the inhaler he originally chose.  Some insurers will pay for drugs that are not on the formulary if the insurer approves.  You can ask about this.  It would be called “Prior Authorization”.

If your doctor feels strongly about which inhaler you need and the insurer refuses to pay, you can pay for the inhaler yourself.  The insurer is not telling your doctor which inhaler to prescribe; it’s telling you which inhaler they will pay for.  Your doctor has to choose another one if you want the plan to pay for it.

So, find out whether the insurer will consider a non-formulary (or non-preferred) inhaler.

Then, take a deep breath and decide what works best for you and your lungs.

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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.