Formulary

Deep dive

Formulary: complete reference

A formulary is the list of prescription medications covered by a specific insurance plan, organized into tiers reflecting cost-sharing and coverage rules. Typical tier structure: Tier 1 (preferred generics, lowest copay), Tier 2 (preferred brand drugs, moderate copay), Tier 3 (non-preferred brands, higher copay), Tier 4 (specialty drugs, percentage coinsurance or highest copay). For GLP-1 medications: diabetes-indicated drugs (Ozempic, Mounjaro, Rybelsus, Trulicity) are typically Tier 3 in commercial plans; weight-management drugs (Wegovy, Zepbound, Saxenda) are often excluded entirely OR placed на Tier 4 с prior auth + step therapy requirements. Self-funded employer plans set their own formularies through PBM contracts — variation is enormous. To check coverage: log into your insurer's member portal, search the formulary tool for the specific brand name (not generic), note the tier + any restrictions (PA, step therapy, quantity limit). Coverage decisions update annually; medications can move between tiers or get excluded.

In practice

Your plan's formulary shows Wegovy as "Tier 4 — Prior Authorization required, $200 copay." That tells you it's covered but with hoops + high cost-share.

Clinical context

Always check formulary before prescribing — coverage variability is enormous especially для weight indications.