Non-Formulary Drugs

Not always. Some non-formulary drugs may be covered if the provider submits a medical necessity exception or prior authorization demonstrating why formulary alternatives are inappropriate. If medical necessity is established and the exception is approved, the patient can often receive the non-formulary drug at the same cost-share as formulary drugs—sometimes even at no additional cost, depending on the plan and patient status. However, coverage and cost-sharing policies vary widely between payers, so it’s important to check the specific requirements of the benefit plan in question.

If you and your provider determine that a non-formulary drug is truly necessary, the approval process generally follows these steps:

• First, check your health plan’s online formulary search tool to confirm the drug’s status and see what information is needed for an exception.
• Download or request the appropriate medical necessity or prior authorization form from your plan’s pharmacy benefit manager (PBM)—this could be OptumRx, Express Scripts, CVS Caremark, or another administrator.
• Complete your portion of the form, then get it to your prescriber. Your provider will need to document why formulary alternatives aren’t suitable (for example: failed therapies, allergies, or unique medical circumstances).
• The provider submits the completed form directly to your PBM, following the instructions included.
• Once approved, medical necessity exceptions typically apply at participating retail pharmacies and through mail-order services, sparing you the hassle of resubmitting for future refills.

By following this route, you’re giving your best shot at accessing the medication you need—even if it means jumping through a few more hoops.

A payer’s Pharmacy & Therapeutics (P&T) committee evaluates clinical and economic data and determines:

• Which drugs to include
• Tier placement
• Whether utilization management applies
  Drugs not meeting criteria or value thresholds may be excluded.

Are non-formulary drugs always more expensive for patients?
Generally yes. Patients may face:

• No coverage (full cash price)
• Higher tier cost-sharing
• Additional UM hurdles
  Even with an exception, out-of-pocket costs may remain higher.

In most cases, non-formulary drugs fall into a therapeutic class where other options—often generic or preferred brand-name drugs—are considered more clinically effective or cost-efficient by the payer. As a result, non-formulary drugs are typically assigned to a higher tier on the plan’s benefit design. This means patients will pay a larger share of the total cost compared to drugs on the generic or preferred brand tiers, either as a higher copay, higher coinsurance percentage, or sometimes the full retail price if the drug isn’t covered at all.

Essentially, if a drug is non-formulary, access comes at a premium. Even when a medical exception is granted, patients may still encounter higher out-of-pocket expenses than they would with formulary alternatives.