How to Read a Formulary with Baylor Scott & White Health Plan

When you find yourself standing in front of the pharmacy counter, you may wonder why some medications are more expensive than expected or why the costs seem to be different from what they were the year before. The answer lies in what’s known as a drug formulary.

With prices increasing, it’s more important than ever to understand what medications your Medicare Advantage plan (if it has prescription drug coverage) or Medicare Part D coverage includes. As a member, you have a right to know your medication benefits from start to finish, but it can feel unclear without all the facts. This blog will teach you how to read a formulary, so you can understand your benefits better.

What is a Formulary?

Formularies are comprehensive lists of drugs that your insurance plan covers. They can include both generic and name-brand drugs, and coverage is updated year-to-year. Staying informed and knowing how to read your formulary will help you know what costs you should expect at the pharmacy counter—and to advocate for yourself if a pharmacist tells you something different. Checking a formulary is an important part when choosing a Medicare Advantage plan or considering switching to a different one.

The first step in reading a formulary is to understand how it is organized. The Baylor Scott & White Health Plan 2025 Formulary for Medicare Advantage is arranged by medical condition. Most formularies also include an index, which lists the names of covered medications alphabetically, in case you aren’t sure which category your medical condition would fall under. Some medicines that are grouped into one category may also be used to treat a different condition. For example, Ozempic® falls within the Blood Glucose Regulators category but may also be prescribed by some physicians for weight loss.

Formularies can be hard to read without knowing the lingo:

• Prior authorization: Some drugs need prior authorization from your insurance to be prescribed. This means you’ll need approval from your insurer before you fill the prescription. If you don’t get this authorization, your insurance may not cover the drug.
• Step therapy: Sometimes, your insurer may require you to try a medication before covering another to treat your condition. For example, if Drug A and Drug B both treat your condition, your insurance may require you to use Drug A before allowing you to fill a prescription for Drug B.
• Drug tiers: Medications are typically categorized into tiers. For Baylor Scott & White Health Plan, these tiers are numbered 1 to 5, based on cost, from lowest to highest. Others can be based on their common usage. Generic drugs are at Tier 1 or 2, while Specialty drugs that are unique and/or high cost are Tier 5. 
• Quantity limits: Some drugs can only be covered in a limited amount per prescription. For example, as of 2025, Baylor Scott & White Health Plan covers a 30-day supply of Caplyta in 42 mg capsules.

Restrictions, tiers and Medicare Part coverage are generally abbreviated in a column next to your medication’s name. In the Baylor Scott & White Health Plan 2025 formulary, you’ll see the following abbreviations:

• BD: Drugs that may be covered under Medicare Part B or Part D, depending on the circumstances. These drugs require prior authorization to determine coverage under Part B or Part D of the Medicare program.
• PA: Prior authorization
• QL: Quantity limits
• ST: Step therapy
• #: High-risk medications that can be unsafe for some patients.
• *: Limited distribution drug that is only available from some pharmacies.
• >: Non-extended day supply, which means the medication is limited to a 1-month supply per prescription.

In the example from Baylor Scott & White Health Plan above, within the category “Analgesics,” you can see that “acetaminophen w/ codeine tab 300-15 mg, 300-30 mg” is labelled with a “>”, meaning it’s a non-extended day supply. It’s at Drug Tier 3, which is a Preferred Brand Drug, and comes with a QL—Quantity Limit—of 360 tablets per 30 days.

Once you grasp the abbreviations and their meanings, reviewing a formulary becomes much easier to understand.

Finding Your Plan’s Formulary

While no website is the same, you have a right to know what your drug costs are going to be. You should be able to find your plan’s formulary on their website. BSW SeniorCareAdvantage members have a plethora of drug information, pharmacy finders and other accessible tools, where you can find your exact plan and location.

Your plan’s resources should be able to guide you to the proper forms and guides for all their options—Part B prior authorization criteria and step therapies, drug reimbursement claim forms, home delivery order forms and more.

Are All Formularies the Same?

No two Medicare Part D plans have the same formulary. Even the tier distinction of different medications may be different. Plans will cover medicines at different rates. When distinguishing what Medicare Advantage plan is best for you, taking a look at Part D formularies can inform you of what medications they may cover during the next year—though formularies can change from one year to the next.

What If Your Medication Isn’t Covered?

You can always request an exception from your insurer, though there is no guarantee that they will choose to cover it. You can usually request for your insurance:

• To cover a drug that’s not on the formulary. This is usually covered at a pre-determined cost-sharing price point.
• To waive a restriction like prior authorization, step therapy or quantity limit.
• To cover a formulary-listed drug at a lower cost-sharing level, unless the drug is on the specialty tier.

Requesting any exemption requires physician assistance. Your doctor will need to provide a valid medical reason to your insurer as to why you must have that specific medication. The decision time depends on your insurance. Baylor Scott & White Health Plan generally makes these decisions within 72 hours of receiving the initial request from your provider and answers requests that require prompt attention within 24 hours.

When choosing your coverage and managing your medications, there are several factors to consider. Contact a Baylor Scott & White Health Plan licensed insurance agent for a consultation on your options and guidance on finding a plan that’s best for you or your loved ones.