Grace's Library

Grace's Library

Understanding Insurance Coverage

Insurance language can feel like its own dialect. Here are a few gentle definitions to help you feel a little more prepared the next time you talk with your provider or your plan.

Formulary

A formulary is the list of medications your insurance plan covers. If a medication isn't on the formulary, it may cost more out of pocket, or your provider may be able to request an exception.

Tiers

Many formularies group medications into tiers. Lower tiers usually cost less; higher tiers usually cost more. Two medications that do similar things can sit on different tiers.

Prior authorization

Prior authorization means your plan wants your provider to submit information explaining why a medication is appropriate for you before it will be covered. It can take a few days.

Appeals

If a medication is denied, most plans allow an appeal. Your provider's office can often help you start one — you do not have to do this alone.

Grace's Thoughts

Insurance can feel overwhelming, and that's not a personal failing. Take it one step at a time, and lean on your provider's office — they navigate this every day.

Questions you may consider asking

  • Is this medication on my plan's formulary?
  • What tier is it on, and is there a lower-tier option?
  • Does it require prior authorization?
  • If it's denied, how would we appeal?

Sources & References

The information on this page is drawn from the sources below.

  1. 1. HealthCare.gov (Centers for Medicare & Medicaid Services). Glossary: Formulary.
    https://www.healthcare.gov/glossary/formulary/
  2. 2. HealthCare.gov (Centers for Medicare & Medicaid Services). Glossary: Drug list (formulary tiers).
    https://www.healthcare.gov/glossary/drug-list/
  3. 3. HealthCare.gov (Centers for Medicare & Medicaid Services). Glossary: Prior authorization.
    https://www.healthcare.gov/glossary/prior-authorization/
  4. 4. HealthCare.gov (Centers for Medicare & Medicaid Services). Appealing a health plan decision.
    https://www.healthcare.gov/appeal-insurance-company-decision/appeals/
  5. 5. Medicare.gov (Centers for Medicare & Medicaid Services). How do I file an appeal?.
    https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal

This is educational, not medical advice. Always talk with your provider about what's right for you.