The short answer
A plan’s formulary lists the medicines included in its insurance cover.
Translate the terms before deciding
Prior authorization requires the insurer’s review and agreement to payment ahead of the prescription being filled.
Ask the insurer what these terms mean for the proposed care. If a reply only says that a drug is “on the list,” ask about the particular use being discussed.
Take a clear question to the plan
- Is the assessment covered, including when done online?
- Does the plan cover this particular product for this use?
- Is advance approval needed, and who asks for it?
- Which pharmacy is covered by the plan for filling this prescription?
- What amount would I pay?
- How can I get the answer in writing?
Ask the clinician for any details the insurer needs to answer. If the plan asks for more information, find out who will send it and how you will hear the result.
Keep the estimate separate from the quote
Bring the insurer’s reply back to the service giving the quote. Ask them to show which charges they expect you to pay. If the answers differ, ask them to resolve the difference before you agree to a plan.
Keep copies of the proposed product name, the coverage reply and the payment terms. If the product or reason for treatment changes, ask the plan the question again with the new details.
It is fine to ask for a plain explanation of a denial or a request for more information. Ask which part of the proposal needs another answer.
Carry this forward
Ask about the particular use and your share of the bill, not just whether a medicine appears on a list.