Managed Care Frequently Asked Questions
Pharmacy Benefits and Formulary Exceptions

What is a drug formulary?

This is a list of medications that your HMO will cover. It must include medications from each category of drugs so that medically necessary medications are available when ordered by your provider. A formulary may not include every drug in each category; it may include generic drugs when they are available. A drug formulary may include step therapy in which certain drugs must be tried and found to be insufficient or unsuccessful before other drugs will be covered. Most drug formularies do not include drugs available over the counter even with a prescription from your provider.

What if the drug you need is not on the formulary?

There may be other drugs on the formulary in the same category as the drug you need. It is up to your provider to determine which formulary drugs may be equivalent to treat your condition. In addition, your provider can seek an exception to the formulary.

What is the process for obtaining an exception to the formulary?

Each HMO has an established process for seeking a formulary exception. Your provider should be familiar with the process and should file the formulary exception request for you. An exception may be requested if the formulary drug is not working for you or causes an allergic reaction, has an adverse interaction with another medication, or your provider can demonstrate that the nonformulary drug will provide the maximum medical benefit for you. You have the right to appeal a formulary exception request that is denied by your HMO.

Will a drug formulary change over time?

Yes, each HMO keeps its formulary current by adding and dropping specific medications based on the recommendations of its physicians and pharmacists.

What is the difference between brand name and generic medication?

There is no difference in the active ingredients between a brand name drug and its generic equivalent. A generic drug may look different than the brand name drug, and may be produced by a different manufacturer. The inactive ingredients will differ. Generic drugs usually cost less than brand name drugs. Your HMO plan may have a higher copay for brand name drugs vs. generic drugs.

For more information, email health.mcs@state.mn.us.