Frequently Asked Questions

Yes. FormCheckRx normalizes 150+ brand aliases automatically. You can enter a generic name (e.g. "lisinopril"), a brand name (e.g. "Prinivil"), a partial name, or an alternate spelling. The system resolves the correct drug entity and returns results for all formulations and applicable MCOs. If you search for a brand that has a generic equivalent, results will show coverage status for both.

Results are typically returned in under 5 seconds for all MCOs in a state. Each query executes in an isolated function context — there is no shared state between requests, and results are processed in real time against current formulary data.

A carve-out occurs when a drug is excluded from an MCO's managed care formulary and must instead be billed through Medicaid Fee-for-Service (FFS). This is common for specialty drugs, REMS medications, and certain high-cost biologics. If a drug appears to be "not covered" by an MCO, it may actually be covered under FFS — but this distinction is invisible to most lookup tools. FormCheckRx's Restriction Detection Agent specifically identifies carve-out status and returns the correct FFS billing pathway so claims are submitted correctly and not rejected.

You can switch states at any time within your account with no additional cost. Cross-state simultaneous comparison is available on the Organization plan — this returns a side-by-side view of formulary status across multiple states for the same drug in a single query. This is particularly useful for multi-state health systems, federal agencies, and organizations serving beneficiaries who move between states.

When a drug is non-preferred or requires prior authorization, FormCheckRx surfaces therapeutically equivalent alternatives in the same drug class that have preferred formulary status across the MCOs in your state. Alternatives are ranked by: (1) preferred status across the most MCOs, (2) tier placement, and (3) clinical relevance to the searched drug class. This allows prescribers to switch to a preferred alternative before initiating a PA, reducing delays for patients.

FormCheckRx sources data from each state's official Medicaid managed care formulary publications, including state-issued Preferred Drug Lists (PDLs), MCO-published formulary files, state pharmacy agency bulletins, and CMS-published formulary data. For Michigan (our fully verified state), all data is cross-referenced against the official Michigan Single Preferred Drug List (SPDL) by a licensed PharmD. For beta states, data is sourced from primary state publications and cross-validated by our AI system but has not yet been manually reviewed by a pharmacist.

FormCheckRx monitors Medicaid managed care publications, PDL updates, PA policy changes, and formulary modifications continuously. Most state PDLs update quarterly; some states like Michigan, Texas, and New York issue off-cycle updates monthly. Each search result displays the source date and verification status so you know how current the underlying data is. We display a timestamp and data vintage on every result. Critical coverage decisions should always be verified against the applicable plan PBM for non-verified states.

Verified — Michigan results have been reviewed in full by a licensed PharmD against the official 2025–2026 Michigan Single Preferred Drug List. Every MCO in the state has been validated. Results are suitable for clinical use. Beta — All other states are available with AI-generated results sourced from primary state publications. Results are labeled "Beta" and the system will indicate that critical decisions should be verified with the plan PBM. Beta coverage is accurate for the vast majority of searches but has not been independently validated by a pharmacist. We are actively expanding PharmD verification to additional states.

FormCheckRx normalizes across NDC codes at the drug entity level. When you search for a drug, the system resolves all applicable NDCs and returns consolidated formulary status. Formulary PDLs are maintained at the drug name/class level rather than the NDC level for most Medicaid managed care plans, so results reflect the applicable coverage policy regardless of which specific NDC is dispensed.

Yes. Federal safety layer data is updated when national guidance changes: the American Geriatrics Society Beers Criteria (updated every 3 years), ISMP High-Alert Medications list, NIOSH Hazardous Drug list, the FDA's REMS database, and Narrow Therapeutic Index classifications. FormCheckRx integrates these as a separate layer from state formulary data — they are always returned in results regardless of formulary status, providing a consistent clinical safety reference.

No. FormCheckRx is not a covered entity or business associate under 45 CFR §160.103 of HIPAA. The platform never receives, stores, processes, or transmits Protected Health Information (PHI) — not a patient name, not a date of birth, not a diagnosis, not a member ID. Searches are conducted using drug names only. Because no PHI ever enters the system, no BAA is required at any plan level, including enterprise and government accounts. This eliminates a procurement barrier that averages 49 days to resolve for PHI-handling vendors.

FormCheckRx is designed to be outside the scope of HIPAA entirely by not handling patient data. Rather than being "HIPAA compliant" (which applies to covered entities and business associates that handle PHI), FormCheckRx simply has no PHI to protect. This is a stronger guarantee than HIPAA compliance — it means there is no possibility of a breach involving patient data, no notification obligations, and no BAA requirement. Healthcare institutions can deploy FormCheckRx faster than any PHI-handling competitor.

FormCheckRx is built on the following security architecture: TLS 1.2+ encryption for all data in transit with downgrade attack blocking; row-level database security; per-endpoint rate limiting; device verification; session management with single-device enforcement; API keys stored as encrypted environment variables (never exposed client-side); each drug query executes in an isolated function context with no persistent server process; and drug queries are processed in real-time and immediately discarded — no search history is retained on FormCheckRx servers. SOC 2 Type II audit is in progress.

Because FormCheckRx handles no patient data, it often does not require the same IT security review as PHI-handling tools. However, institutional policies vary — some organizations require review of all clinical software regardless of PHI handling. The platform's no-PHI architecture, combined with the absence of a BAA requirement, means it typically clears institutional procurement review significantly faster than EHR-integrated tools or formulary systems that handle member data. Contact [email protected] to obtain a security summary document for your IT department.

No. FormCheckRx is a formulary intelligence platform — it tells you whether a PA is required and what the clinical criteria are. It does not submit PA requests on your behalf. The platform is designed to be used before initiating prescribing, allowing you to identify the correct coverage pathway (preferred drug, PA criteria, FFS carve-out, or covered alternative) so that PA requests — when required — are submitted with the correct documentation the first time.

For plans where PA criteria are available in machine-readable form, FormCheckRx returns the full clinical criteria including: required diagnosis codes (ICD-10), prior therapy/step therapy documentation requirements, prescriber specialty requirements, age or weight criteria, duration of trial for step therapy, authorization period, and renewal criteria. The criteria are displayed in plain clinical language accessible to non-pharmacy staff. For plans where detailed criteria are not available in the plan's published formulary files, FormCheckRx indicates that PA is required and provides the plan's PA submission contact.

Most prior authorizations are triggered by prescribing a non-preferred drug when a preferred alternative in the same class exists. When prescribers and care coordinators know the formulary status before writing the prescription — rather than learning about it after a claim rejection — they can select a covered preferred drug that requires no PA at all. The AMA's 2024 survey found that 93% of physicians report PA delays patient care and 82% of patients abandon treatment due to PA problems. FormCheckRx addresses the problem at the source: formulary lookup before prescribing, not PA management after rejection.

All 50 states and the District of Columbia are available. Michigan is fully PharmD-verified. All other states are available in beta. You can switch states at any time from within your account. See the States page for a complete coverage table including PDL structure, MCO count, and update frequency for each state.

In states with a Single PDL (like Michigan's SPDL, Pennsylvania's Statewide PDL, or Mississippi's Universal PDL), all MCOs are required to use the same preferred drug list. This means FormCheckRx returns the same formulary status for all plans. In states with MCO-individual PDLs, each MCO maintains its own formulary — and a drug may be Preferred under one plan and Non-Preferred with PA required under another. The clinical complexity of MCO-individual PDL states is exactly why FormCheckRx exists: without a tool that searches all plans simultaneously, manual comparison is impossible at scale.

Coverage varies by state. In most states, CHIP pharmacy benefits are managed through the same MCOs and PDLs as Medicaid managed care. In states where CHIP uses a separate formulary (such as Texas, which maintains separate CHIP and Medicaid formularies through the Vendor Drug Program), FormCheckRx reflects the applicable state policies. The search result will indicate which program's formulary applies to the result returned.

Each drug search is one query. Searching "metformin" in Michigan returns results across all 11 Michigan Medicaid MCOs simultaneously — that counts as one query. Switching the state on the same drug, applying different filters, or viewing a result again does not consume additional queries. Each query on Organization plan is shared across the team's query pool.

PDF export is available on Professional (30 exports/month), Clinic (unlimited), and Organization (unlimited) plans. PDFs include full formulary results, PA criteria, safety flags, covered alternatives, a timestamp, the data source, and verification status. Timestamped PDFs serve as documentation records for compliance and claims support.

Yes. You can cancel your subscription at any time from your account settings. Cancellations take effect at the end of the current billing period. You will retain full access until the period ends. Annual plan refund policies are described in the Terms of Service.

Yes. Enterprise API access is available for hospital systems, state Medicaid agencies, managed care organizations, and health plan administrators. The API returns structured JSON results for all fields including formulary status, PA requirements, PA criteria, quantity limits, safety flags, and covered alternatives. API keys are stored as encrypted environment variables and are never exposed client-side. Contact [email protected] for API documentation and integration support.

The 60-day evaluation includes: full Organization-level feature access (20,000 queries/month, 15 seats, unlimited PDF exports, batch medication check, cross-state comparison, admin dashboard, usage analytics), API access with full documentation, dedicated onboarding with a FormCheckRx team member, and priority support for the evaluation period. No credit card is required to start. The evaluation is available to hospital systems, state agencies, managed care organizations, and tribal health programs. Contact [email protected] to request access.

Yes. The Enterprise API is designed for integration into MMIS systems, eligibility platforms, case management tools, EHR workflows, and other clinical systems. Because FormCheckRx handles no patient data, integration does not introduce PHI into the API layer. Drug name queries are sent; formulary results are returned. White-label licensing is also available for organizations that want to embed FormCheckRx functionality under their own brand. Contact [email protected] for integration specifications.

In many cases, yes. Because FormCheckRx handles no PHI, it bypasses the BAA requirement that triggers formal procurement review for most clinical software. Government agencies may be able to deploy FormCheckRx under existing software subscription authority without a full IT security review, depending on their agency's policies. We provide a security summary document on request that outlines the no-PHI architecture, encryption standards, and access controls for IT review teams. The 60-day evaluation can begin while formal procurement is in progress.

State Medicaid agencies (pharmacy directors, managed care oversight staff, beneficiary services), county and local human services (DHS/DSS caseworkers serving SNAP, TANF, and Medicaid clients), community health workers and patient navigators employed by county health departments and FQHCs, corrections and reentry health programs, tribal health programs and Indian Health Service, and state behavioral health authorities. Any government staff who help Medicaid beneficiaries access medications need to know what each plan covers — that is precisely what FormCheckRx returns.

Yes. Custom pricing is available for state agencies, county health departments, tribal health programs, and federal government entities. Government pricing reflects the scale of deployment and the public health mission of the organization. Contact [email protected] with your agency name, use case, and estimated user count for a proposal.