Insurance
17 columns
100 rows
8 formats

Drug Formulary and Coverage Tiers

This dataset provides a comprehensive mapping of insurance formularies to covered drugs, detailing coverage tiers, prior authorization and step therapy requirements, quantity limits, and specialty drug management programs. It is ideal for pharmacy benefit analysis, formulary comparison, and regulatory reporting, supporting informed decision-making for healthcare providers, payers, and patients.

last updated 2 Nov 2025
by GoMask

The brief that made it

Pharmacy benefit management and formulary optimization

Sample rows

preview · 8 of 100 rows · all 17 columns

formulary_idstring	coverage_tierstring	quantity_limitinteger	specialty_drugboolean	specialty_management_programstring	formulary_namestring	insurance_plan_idstring	insurance_plan_namestring	drug_idstring	drug_namestring	drug_ndcstring	prior_authorization_requiredboolean	step_therapy_requiredboolean	quantity_limit_periodstring	effective_datedate	expiration_datedate	coverage_notesstring
FMLRY10001	Tier 1	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001101	Atorvastatin Calcium	12345-6789-01	false	false	per month	2024-01-01	2024-12-31	Standard coverage for cholesterol reduction.
FMLRY10002	Tier 1	60	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001102	Metformin HCL	23456-1234-02	false	false	per month	2024-01-01	2024-12-31	Covered for diabetes management.
FMLRY10003	Tier 1	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001103	Lisinopril	34567-2345-01	false	false	per month	2024-01-01	2024-12-31	First-line coverage for hypertension.
FMLRY10004	Tier 2	90	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001104	Levothyroxine Sodium	45678-3456-02	false	false	per prescription	2024-01-01	2024-12-31	Standard coverage for thyroid hormone replacement.
FMLRY10005	Tier 2	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001105	Omeprazole	56789-4567-02	false	false	per month	2024-01-01	2024-12-31	Acid reflux treatment. No restrictions.
FMLRY10006	Tier 2	1	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001106	Fluticasone Propionate	67890-5678-01	true	false	per day	2024-01-01	2024-12-31	Prior authorization required for chronic asthma.
FMLRY10007	Tier 3	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001107	Sertraline HCL	78901-6789-01	false	true	per month	2024-01-01	2024-12-31	Step therapy required: must try Tier 1 antidepressants first.
FMLRY10008	Tier 3	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001108	Clopidogrel Bisulfate	89012-7890-01	true	true	per month	2024-01-01	2024-12-31	Step therapy and prior authorization required for cardiac events.
FMLRY10009	Tier 4	2	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001109	Albuterol Sulfate	90123-8901-02	false	false	per week	2024-01-01	2024-12-31	Covered for acute asthma attacks.
FMLRY10010	Specialty	2	true	RheumaCare Program	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001110	Adalimumab	01234-9012-01	true	true	per month	2024-01-01	2024-12-31	PA & step therapy for rheumatoid arthritis. Managed via RheumaCare.
FMLRY10011	Specialty	1	true	RareDiseaseRx	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001111	Eculizumab	12345-0123-01	true	false	per week	2024-01-01	2024-12-31	PA for rare disease; managed through RareDiseaseRx.
FMLRY10012	Tier 4	30	false	blank	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001112	Truvada	23456-1234-02	true	false	per month	2024-01-01	2024-12-31	PA for HIV PrEP.
FMLRY10013	Specialty	4	true	EndoSpecialty	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001113	Ozempic	34567-2345-01	true	false	per month	2024-01-01	2024-12-31	Specialty management for diabetes.
FMLRY10014	Specialty	2	true	ImmunoRx	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001114	Humira	45678-3456-02	true	true	per month	2024-01-01	2024-12-31	PA & step therapy for autoimmune disorders.
FMLRY10015	Specialty	2	true	ImmunoRx	PrimeCare Select 2024	INSPLN5001	PrimeCare Silver PPO	RX001115	Enbrel	56789-4567-02	true	true	per month	2024-01-01	2024-12-31	Specialty management for arthritis.
FMLRY10016	Tier 1	30	false	blank	PrimeCare Bronze Choice	INSPLN5002	PrimeCare Bronze PPO	RX002101	Simvastatin	67890-5678-01	false	false	per month	2023-07-01	2024-06-30	Generic cholesterol drug, standard coverage.
FMLRY10017	Tier 1	30	false	blank	PrimeCare Bronze Choice	INSPLN5002	PrimeCare Bronze PPO	RX002102	Amlodipine Besylate	78901-6789-01	false	false	per month	2023-07-01	2024-06-30	Covered for hypertension.
FMLRY10018	Tier 2	60	false	blank	PrimeCare Bronze Choice	INSPLN5002	PrimeCare Bronze PPO	RX002103	Hydrochlorothiazide	89012-7890-01	false	false	per prescription	2023-07-01	2024-06-30	Covered as second-line diuretic.
FMLRY10019	Tier 2	90	false	blank	PrimeCare Bronze Choice	INSPLN5002	PrimeCare Bronze PPO	RX002104	Gabapentin	90123-8901-02	true	false	per prescription	2023-07-01	2024-06-30	PA for off-label pain management usage.
FMLRY10020	Tier 3	30	false	blank	PrimeCare Bronze Choice	INSPLN5002	PrimeCare Bronze PPO	RX002105	Bupropion HCL	01234-9012-01	false	true	per month	2023-07-01	2024-06-30	Step therapy required: must try Tier 2 antidepressants first.

What the 100 rows show

from the 100-row sample

Specialty (coverage tier) stands out: 25 of its 25 rows have specialty_drug = true, against 6 of 75 for the rest.

31%specialty_drug = true
30median quantity_limit
4quantity limit periods
16formulary names
16insurance plans
16insurance plan names

Specialty drug rate by coverage_tierspecialty_drug = true

quantity_limit100 rows, in bands of 10

Median 30, from 1 to 90.

specialty_management_program31 rows with a value · 69 left blank

Immunology Specialty7
NeuroRx6
Diabetes Specialty6
Respiratory Specialty Program4
ImmunoRx2
RheumaCare Program1
RareDiseaseRx1
EndoSpecialty1
Specialty Care Connect1
Rheumatology Specialty1

17 columns by typefrom the column list below

string 11
integer 1
date 2
boolean 3

Columns

17 columns in four groups

blueprint · 17 columns
column	type	description	example
Text 11 columns
`formulary_id`	string	Unique identifier for the insurance formulary.unique	FMLRY10001
`formulary_name`	string	Name of the insurance formulary.	PrimeCare Select 2024
`insurance_plan_id`	string	Unique identifier for the insurance plan associated with the formulary.	INSPLN5001
`insurance_plan_name`	string	Name of the insurance plan.	PrimeCare Silver PPO
`drug_id`	string	Unique identifier for the drug.	RX001101
`drug_name`	string	Commercial or generic name of the drug.	Atorvastatin Calcium
`drug_ndc`	string	National Drug Code (NDC) for the drug.optional	12345-6789-01
`coverage_tier`	string	Coverage tier for the drug (e.g., preferred generic, non-preferred brand, specialty).8 values	Tier 1
`quantity_limit_period`	string	Period for the quantity limit (e.g., per day, per month).per day · per week · per month · per prescription · other · optional	per month
`specialty_management_program`	string	Name of the specialty drug management program, if applicable.11 programs · optional	RheumaCare Program
`coverage_notes`	string	Additional notes or comments about coverage, restrictions, or exceptions.optional	PA for HIV PrEP.
Numbers 1 column
`quantity_limit`	integer	Maximum quantity allowed per prescription period (e.g., per month).1 or more · optional	30
Dates and times 2 columns
`effective_date`	date	Date when the formulary coverage for this drug becomes effective.	2024-01-01
`expiration_date`	date	Date when the formulary coverage for this drug expires.optional	2024-12-31
True or false 3 columns
`prior_authorization_required`	boolean	Indicates if prior authorization is required for this drug.	false
`step_therapy_required`	boolean	Indicates if step therapy is required for this drug.	false
`specialty_drug`	boolean	Indicates if the drug is classified as a specialty drug.	false

Use it for

An insurance dashboard
The specialty_drug rate, quantity_limit by coverage_tier and a breakdown of specialty_management_program. Excel, Power BI or Tableau.
Why do 31 of 100 rows have specialty_drug = true?
A root-cause class exercise
Hand out the rows and one question. The answer is in the data, not in the brief.
Formularies100
FMLRY1000130Tier 1
FMLRY100102Specialty
FMLRY100111Specialty
A software demo
Believable formularies with formulary_name, insurance_plan_id and insurance_plan_name to fill a screen in front of a buyer.

This dataset100 rows17 columns

Yours10,000 rows17 columns

blueprint · drug-formulary-and-coverage-tiers

Behind this dataset

Same schema. As many rows as you need.

These 100 rows came out of a blueprint — 17 columns with generation rules behind each one. Open it in Data Factory to retune a column, add your own, wire in foreign keys, and run it at the size you actually need.

Rules it was built with

Formulary ID unique per plan
Drug name and RxNorm or NDC
Coverage tier: Tier 1 (generic), Tier 2 (preferred brand), Tier 3 (non-preferred), Tier 4 (specialty)
Copay amounts by tier
Preferred vs non-preferred status
Prior authorization required indicator
Step therapy requirements (try drug A before drug B)
Quantity limits per prescription or per month

Rows1,000 rows10,000 rows100,000 rows1,000,000 rows

Open the blueprint in Data Factory

1 credit per row. New accounts start with 25 free credits.

Exports: CSV, JSON, JSONL, Parquet, SQL, Excel, TSV, XML
Licence: yours to use, including commercially
API slug: drug-formulary-and-coverage-tiers

What should your data show?

No signup. No card.

Sample rows

What the 100 rows show

Columns

Use it for

An insurance dashboard

A root-cause class exercise

A software demo

Make it yours.

Same schema. As many rows as you need.

More in Insurance

What should your data show?