Start with the plan's drug list
A formulary is the list of prescription drugs covered by a plan. Finding a medicine on that list is a useful first step, but you should also confirm the cost and coverage conditions with the insurer. HealthCare.gov recommends reviewing the insurer's drug list, coverage materials, and Summary of Benefits and Coverage, or calling the insurer directly.
Create your own medication list before comparing plans. Copy each medicine's name and the details on its label so that your questions are precise rather than based on a name you partly remember.
Ask about requirements and pharmacies
Some prescriptions may require preauthorization, also called prior authorization or prior approval. This is a plan decision about medical necessity; it is not a promise that the cost will be covered. Ask what steps the plan and prescriber must complete for your particular medicine.
Pharmacy networks vary too. Confirm whether your usual pharmacy participates and ask about mail delivery if it would be helpful. Do this for the specific plan you are considering.
Fictional example: checking before a refill
Sam keeps a note for each regular medicine while comparing fictional plans. The note includes the name from the label, the pharmacy used, and three open questions. Sam calls with the plan details ready and records the answers without interpreting silence as approval.
If an answer is unclear, Sam marks it for follow-up with the insurer and prescriber. Sam also writes down when the next refill is expected so the conversation happens with time to resolve a problem. This is an organizing example, not advice to change a medication or delay treatment.
Practical prescription checklist
If a prescribed drug is not normally covered, ask about the plan's drug exceptions process. An insurer can explain the process, and the prescriber may need to provide supporting information. A denied request can also be appealed.
- Check each regular medicine in the current formulary.
- Confirm the cost and any approval requirements.
- Verify the exact pharmacy you expect to use.
- Ask who must submit any required information.
- Record the contact and answer for unresolved questions.
- Discuss coverage problems with your prescriber before changing treatment.