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    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?

    All health plans for sale in your state's Marketplace must offer prescription drug coverage, as well as those sold on the individual market or offered through a small employer. It's one of 10 essential helath benefits that plans must have, according to the Affordable Care Act. Large employers (those with 50 or more employees) are not required to offer the essential health benefits, but nearly all do.

    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. All plans sold on the Marketplace are required to have an exception process to request access to off-formulary drugs.

    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.

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