If a drug is not on the formulary, what should a beneficiary do to obtain coverage for the drug?

• A. Request prior authorization or use an alternative drug that is on the formulary
• B. Pay full price without any authorization
• C. There is no way to get it covered
• D. You must change plans

Answer: (A)

When a drug isn’t on the formulary, you can still get coverage by having the prescriber request prior authorization or by using a formulary-approved alternative. The formulary is the plan’s approved list of covered medications; if a drug isn’t on it, the plan usually won’t cover it unless an exception is granted. Prior authorization involves the plan reviewing medical necessity before approving coverage, and if approved, you’d pay the usual cost-sharing under your plan. If the request is denied, you can appeal or you can work with your prescriber to switch to a similar drug that is on the formulary. Paying full price isn’t the standard route because non-formulary drugs typically require authorization or an approved exception before coverage. Changing plans isn’t required just to obtain coverage for a specific drug, unless you’re considering overall plan options.