The 2026 Formulary Flip | Is Your Med Still Covered? | Simplefill

In 2026, some healthcare plans are removing certain medications from their formularies. Some may not be fully removing them but could instead require prior authorization or step therapy before you can access the drugs you need. As a result, you could struggle to afford lifesaving medications for chronic conditions like asthma or HIV. 

Why are these changes occurring, and how can you know if your medications are affected?

What Are Medication Formularies?

A medication formulary is the list of drugs covered by a health plan. These medications are arranged by tiers, with lower tiers meaning lower costs. Healthcare plans and systems state that the decisions they make regarding formularies are all evidence-based. 

When making changes, a number of factors are taken into consideration. These include the therapeutic benefits of the medication and its cost-effectiveness. 

Sometimes, step therapy is required. This means you would have to try cheaper medications first. Other medications will require prior authorization before being available. 

These are dynamic lists that are updated frequently. If new drugs or different treatment options become available or medical guidelines change, health plans will look into adjusting their formularies.  

How Can You Check Formulary Changes?

If you take medications for chronic conditions, it’s always important to check for formulary changes as the new year starts. This may not be a simple process, especially if you’ve never done it before. 

Often, health plans have online drug search tools you can rely on. There may be “Drug Search” or “Formulary Search” options. Sometimes, a health plan’s website might have a “Drug List” on the pharmacy section. 

By typing the name of your medication into these search tools, you can learn if it’s still an accepted option, if it remains in the same tier, and whether there are any special requirements. 

On the site, you may also be able to find lists of the formulary changes for that year. These lists tend to be available as PDFs that offer all of the information you need to know about changes in tiers, restrictions, and more. 

It’s also possible to call the number on your member ID card. This allows you to speak with a representative, who can offer all of the information you need. There could also be real-time prescription price tools that can give you an idea of what you can expect to pay at the pharmacy. 

Most often, you will know about these changes before they occur because you’ll be sent notifications about anything that can significantly impact you. However, smaller changes, like the addition of a generic medication that could save you money every month, might not be part of those notifications. 

Can You Request Exceptions to Formulary Changes?

It is possible to request an exception if your health plan no longer covers your medication, has moved it to another tier, or has added restrictions to it. You will need to speak with your doctor about this because they will have to provide a supporting statement regarding why you need the medication. 

They’ll have to show evidence that other similar medications won’t work as well. For standard requests, most plans have to get back to you with an answer within 72 hours. For expedited requests, they have 24 hours. 

Get Affordable Access to Prescription Medications

Simplefill is a full-service prescription assistance company that researches, qualifies, and maintains patients’ enrollment in all sources of assistance available to them.

Apply today by calling 877-386-0206. A caring Simplefill representative will contact you within 24 hours to discuss your application and, if qualified, enroll you in the program.

Frequently Asked Questions

Do you have more questions about formularies? These answers may help. 

What Happens if My Request for an Exception Is Denied?

If your request is denied, you may be able to begin an appeal. It can be important to consult with your doctor to see how you can provide further evidence regarding your medication needs. 

What Evidence Can My Doctor Submit to Show That I Need an Excluded Medication?

If you have tried other medications for the condition before, it’s important to offer information on the kind of effect they had on you. If they caused side effects or were not as helpful in treating your symptoms, that can be a persuasive argument toward granting you the exception. 

What Are the Consequences of a Drug Moving Up a Tier?

If a drug moves up a formulary tier, it can mean a significant difference in cost. If you have a tier 2 drug that moves into tier 3, it will be a less-preferred drug, so you’ll have higher out-of-pocket costs.