Formularies are lists of medications that insurance companies use to inform members which drugs are covered under their pharmacy benefits. They are usually found as a PDF document and are notorious for being difficult to comprehend. It is for just that reason that we have created a step-by-step guide to help you navigate a drug formulary - and actually understand what it means.
Say, for example, you were trying to look up benefits for lisinopril, a common blood pressure medication.
To begin, turn to the table of contents - and yes, there is a table of contents.
Here you will find a list of drug categories. First, you must know the category for your medication: lisinopril. Depending on the layout of your formulary, lisinopril could fall under a few different categories.
In our lisinopril example, we are going to navigate to the “cardiovascular” section. Now that you’ve found the right category for your medication, you now have to figure out what the class of the medication is. What is the difference between a category and a class, you ask? A category is a broader group of medications while a class is more specific. In this case, under the cardiovascular category, our class choices are: ace inhibitors, adrenolytics, antiarrhythmics, beta-blockers, calcium channel blockers, and diuretics… to name a few. Lisinopril falls into the class known as angiotensin-converting enzyme inhibitor or ACE inhibitor for short. Now that we found the drug class (ACE Inhibitors), we can head to page 14 of the drug formulary.
After a quick search on the page - we’ve successfully located lisinopril. Good news, if you see the drug on this page, it means you’re covered!
Let’s see what else we can learn. Lisinopril is in bold text. If we navigate back to the legend (page 7), we can fairly easily find out that what that means.
According to the legend, boldface “indicates generic availability”. Well, now we know that lisinopril is generic. But how much is it going to cost? This takes a little more work on your part. Your prescription copays might be located on your insurance card. If not, you’ll need to refer to your pharmacy benefit documents provided by your insurance company. If you have a copay plan, you will need to determine what your generic copay is. These are usually tier one medications. Looking at a personal insurance example, tier 1 copays come in at $8. So, after all of this work, we can assume that a prescription for lisinopril will cost $8 with our insurance. For high deductible plans, you need to determine if you have met your deductible. If not, you will most likely be paying the full cost of the drug - and you won’t know that until you checkout at the pharmacy.
Why is it so much work to find out drug coverage?
A great question indeed. At PokitDok, we are building the technology to streamline and simplify this complex process. We replace paper with software and make looking up medications simple. The image below shows how simple it is to look up lisinopril using PokitDok...instead of going through the process outlined above. The image below is an example of a lookup tool powered by PokitDok’s formulary API.
Using our Pharmacy API doesn’t require a pharmacy school education, nor the time wasting commitment required to shuffle through PDFs, and google search results. You simply enter the member’s information, type in a drug, and receive coverage information. You know instantly, if the drug is covered, if there any restrictions, and what the cost of the drug will be for the insurance policy at hand.