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

With drug prices increasing, it’s more important than ever to understand what medications your 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 (also referred to as drug lists) are comprehensive lists of drugs that your insurance plan covers. They can include both generic and name-brand drugs, and the formulary is updated routinely. 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. Checking the 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 Medicare Formulary is arranged by medical condition. The formulary also includes an index, which lists the names of covered medications alphabetically, in case you aren’t sure which category your medication would fall under.

Formularies can be hard to read without knowing the lingo:

• Prior authorization: Some drugs need prior authorization from your plan to be prescribed. This means you’ll need approval from your plan before you fill the prescription. If you don’t get this authorization, your plan may not cover the drug.
• Step therapy: Sometimes, your plan 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 plan 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 most Baylor Scott & White Health Plan Medicare formularies, there are five drug tiers. Generic drugs are generally in Tiers 1 and 2, preferred brand drugs are in Tier 3, non-preferred drugs are in Tier 4 and specialty drugs that are unique and/or high cost are in Tier 5. 
• Quantity limits: Some drugs can only be covered in a limited amount per prescription. For example, in 2025, Baylor Scott & White Health Plan covers a 30-day supply of Caplyta 42 mg capsules.

The drug tier and any applicable restrictions are noted in columns next to your medication’s name. In the Baylor Scott & White Health Plan Medicare 2025 formulary, you’ll see the following abbreviations for medication restrictions:

• 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.

For example, Ozempic is listed on the Baylor Scott & White Health Plan Medicare formulary under “Blood Glucose Regulators” at Tier 3, as a preferred brand drug.  Additionally, Ozempic requires prior authorization and has a quantity limit of 1 pen per 28 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.  The BSW SeniorCare Advantage website contains a variety of resources and tools to assist members in understanding their Medicare Part D coverage. This includes pharmacy, formulary and prior authorization documents along with pharmacy and formulary search tools.

Are All Formularies the Same?

No two Medicare Part D plans have the same formulary. When choosing the best Medicare Advantage plan for you, reviewing Part D formularies can help you understand which medications they may cover next year, including drug tiering and any restrictions.

What If Your Medication Isn’t Covered?

You can request an exception from your plan for coverage consideration. You can request for your plan:

• To cover a drug that’s not on the formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask your plan to provide the drug at a lower cost-sharing level.
• To waive a restriction like prior authorization, step therapy or quantity limit.
• To cover a formulary drug at a lower cost-sharing tier, unless the drug is on the specialty tier (Tier 5). Generally, your plan will only approve your request for a tier exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or applying the restriction, would not be as effective for you and/or would cause you to have adverse effects.

If you’re a BSW SeniorCare Advantage member, you or your prescriber should contact us to request a tiering or formulary exception, including an exception for a coverage restriction. When you submit an exception, your prescriber will need to explain the medical reasons why you need the exception. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can ask for an expedited (fast) exception if you believe, and we agree, that your health could be seriously harmed by waiting up to 72 hours for a decision. If we agree, or if your prescriber asks for a fast decision, we must give you a decision no later than 24 hours after we receive your prescriber’s supporting statement.

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.