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Health Care Reform:

Health Insurance & Affordable Care Act

Prescription Drug Costs and Health Reform: FAQ

If you take a more than a few medicines and you're choosing a health insurance plan, look closely at each plan's drug benefits. Doing that homework could save you money on your prescriptions for the next year.

Got questions about prescription coverage? These answers may help you  prepare and feel confident about comparing prescription benefits between health plans.

Do all health plans cover prescription drugs?

Yes. All health plans for sale in your state's Marketplace must offer prescription drug coverage. It's one of 10 essential benefits that plans must have, according to the Affordable Care Act.

Check the summary of benefits for plans offered by your employer to see if it covers prescription drugs.

Are prescription drug plans the same in every state?

No. All health plans in a Marketplace must include prescription drug coverage, but each state sets the list of covered medicines, called the formulary. For instance, one plan may have many more medicines in one category or class than another state does.

How do I know if a health plan will cover the medicines I take?

Check the plan's formulary, also known as a preferred drug list. You should be able to get this from any health plan you're considering. Sometimes a plan's formulary will be on its web site.

The formulary lists each brand and generic name of medicines that the plan will help pay for. To look for your medicines, you need to know:

  • The medicine's exact name
  • The dose you take
  • How many pills your doctor usually prescribes

Keep in mind that formularies can change. Medicines can be added or removed. A generic drug can replace a brand name one. Or one generic drug can replace another generic drug.

What if my medicine isn't on a plan's formulary?

If you can't find your medicine on a health plan's drug list in your state's Marketplace, you can request that your plan cover it or give you access to it.

You can request that your insurer cover a medication not on its formulary with the help of your doctor to explain the medical need.  If your request is denied, you have the right to appeal your health plan's decision.

What will I pay for medicines?

With some health plans, you pay a coinsurance for your medicines. This is a set percentage of the drug's cost, such as 30%. With some health plans, you pay a prescription copay, which means you pay a fixed amount for each medicine you buy.

Many formularies have two or more cost levels, called tiers. The copayment for each tier will likely be different.  Higher level tiers cost you more. For instance, a third tier medicine costs more than a first tier one.

Many health plans have three or four tiers of costs:

  • Tier 1: Generic medicines, which cost the least
  • Tier 2: Preferred, brand-name medicines
  • Tier 3: Non-preferred, brand-name medicines
  • Tier 4: Specialty medicines, which are often costly, brand-name medicines. For instance, chemotherapy may be a fourth tier medicine.

Keep in mind that you may have a separate deductible for prescription drugs. You may need to pay it as well as a deductible for medical services. Look at a plan's summary of benefits about prescription medicines to see what you'd be responsible for paying.

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