Two plans with identical premiums and deductibles can treat your prescriptions completely differently. If you take a medication regularly, checking the plan's drug list — the formulary — should come before comparing prices.
What a formulary is
A formulary is the plan's list of covered prescription drugs. Each plan has its own, and insurers update them every year. A drug that is not on the formulary may not be covered at all except through an exception request.
How to look up your drug
- Find the plan's formulary from its plan details page or the insurer's website. Make sure it is the formulary for the coming year.
- Search by both the brand and generic name.
- Note the tier and any letters beside the drug, such as PA, ST, or QL.
On the marketplace, you can often enter your medications while shopping and filter plans that cover them.
What drug tiers mean
| Tier (typical) | Usually includes | Your cost |
|---|---|---|
| Tier 1 | Preferred generics | Lowest copay |
| Tier 2 | Non-preferred generics, some brands | Low to moderate copay |
| Tier 3 | Preferred brand-name drugs | Higher copay or coinsurance |
| Tier 4+ | Specialty drugs | Often coinsurance, sometimes after the deductible |
Plans number and label tiers differently, so read each plan's own definitions.
The restrictions to look for
- PA — prior authorization: your doctor must get approval before the plan pays.
- ST — step therapy: you may need to try a lower-cost drug first.
- QL — quantity limit: the plan caps how much you can fill at once.
These are not deal-breakers, but they add paperwork and delay. If your current medication works, a plan without these hurdles for it has real value.
Estimating your annual drug cost
Multiply your per-fill cost by fills per year, and check whether drug costs count toward your deductible first. For expensive medications, a plan with a higher premium and better drug coverage often costs less over the year. Weight-loss and diabetes drugs are a good example — see whether insurance covers Ozempic and Wegovy.
If your drug is not covered
You can ask your doctor about a covered alternative, request a formulary exception, or choose a different plan while Open Enrollment is still open. Checking before December 15 keeps all three options available.
Want us to check your medications across every plan? Our free tool compares plans across top carriers and shows what you would actually pay in about 60 seconds — no obligation, and a licensed agent reviews your options with you. Get your free quote →