How to read your prescription drug formulary
A formulary helps you understand what medications are covered by your pharmacy benefit and how much you will pay for those medications, as well as special considerations for some medications. Use this guide to help you understand your pharmacy benefit’s formulary.
Formulary example and definitions
Use the definitions below to help you understand the information within each formulary column.
Drug Name
Medications are listed in alphabetical order. This column includes the medication name as well as other identifying information. UPPERCASE letters indicate brand-name medications and lowercase letters indicate generic medications.
It is helpful to know your medication’s active ingredient or generic name. Then you can search the formulary for the medication by clicking the magnifying glass in the PDF toolbar or type CTRL+F to open the “Find” feature.
Special Code
This column includes letter codes to indicate special considerations for some medications. A key for these letter codes is included at the bottom of every formulary page, but here are definitions for some of the most common codes:
- QL = Quantity Limit drugs are limited in the number of doses you can receive at one time.
- PA = Prior Authorization drugs require additional information from your provider to ensure the medication is right for your situation.
- SF = Split Fill drugs are limited to two 15-day fills per month for the first three months to confirm the medication is right for your situation before filling a larger supply.
- ST = Step Therapy drugs are high-cost medications that may only be prescribed after trying a less costly, clinically equivalent drug first.
- MSP or LD = Mandatory Specialty Pharmacy or Limited Distribution drugs are specialty medications that require special coordination for chronic or complex health conditions.
- RDX = Restricted-to-diagnosis drugs may only be prescribed for a specific medical diagnosis.
- RS = Restricted-to-specialist drugs may only be prescribed by a specialist provider.
Things to note
- For both the Signature and HSA Advantage Plans, special codes may affect if a prior authorization is needed, where you can fill the prescription and how many days’ supply you can receive.
- Special codes – particularly MSP or LD – combined with tiers (defined below) affect Signature Plan copays. Learn more about how copays and coinsurance work in our guide to understanding how you and the health system share the cost for your healthcare expenses.
It is helpful to know your medication’s active ingredient or generic name. Then you can search the formulary for the medication by clicking the magnifying glass in the PDF toolbar or type CTRL+F to open the “Find” feature.
Tier
This column includes number or letter codes to indicate medication cost tiers.
- Tier 1 = Primarily generic medications, which are the most cost-effective option for many disease states. Generic drugs must work in the same way and provide the same clinical benefit as their brand-name counterparts to be approved by the Food and Drug Administration (FDA).
- Tier 2 = Includes lower-cost brand name medications and some higher-cost generics.
- Tier 3 = Contains higher-cost brand-name medications, often with lower-cost brand or generic alternatives that provide the same clinical benefit.
- Tier 4 = The most expensive non-specialty brand-name medications, typically with lower-cost alternatives that provide the same clinical benefit.
- NC = This medication is not covered. You may want to talk with your provider about an alternative medication.
- 50% = 50% coinsurance is required for this medication, regardless of your medical plan.
- OC = This is an oral chemotherapy medication.
Things to note
- Tiers combined with special codes (defined above) – particularly MSP or LD – affect Signature Plan copays.
- Tiers do not affect HSA Advantage Plan coinsurance percentages but choosing lower-cost generics vs. higher-cost brands can affect coinsurance
- Learn more about copays, deductible and coinsurance in our guide to understanding how you and the health system share the cost for your healthcare expenses.
If you know your medication’s brand name, you can check for a generic equivalent. Click the magnifying glass in the PDF toolbar or type CTRL+F to open the “Find” feature, then type the brand name plus “equiv” in the search bar. The search results will reveal any available generics.
Category
This column indicates a class or category for each listed medication, such as analgesics, beta-blockers, corticosteroids, diuretics, etc.
It is helpful to know your condition’s medical name or your medication’s medical action. Then you can search for the condition or action to find similar medications that may have a lower cost.
The Navitus formulary is subject to change throughout the year. For the most up-to-date information on your prescription medications, log in to the Navitus member portal or mobile app.
Use the information on your pharmacy ID card to get started.