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Health Care Reform:

Health Insurance & Affordable Care Act

Managing the Cost of a Chronic Condition: FAQ

How much of my prescription drug costs will health insurance cover?

Prescription drug coverage varies with the type of plan you have. To see exactly what a plan covers, look at its summary of benefits, coverage, and its list of included drugs.

Be aware that plans may charge a separate deductible for prescription drugs in addition to the one they have for other medical care. The limits are the same for each deductible -- $6,600 for one person and $13,200 for a family.

Most people will have to pay less for generic medicines than for brand-name drugs.

You probably won't pay the same amount for all brand-name drugs either. Many plans cover medicines by tiers. The higher the tier number, the more the medicine will cost you. For instance, a tier-3 medicine costs you more than a tier-1 medicine.

Take time to look at the drug formulary -- a list of prescription medicines a health plan covers -- for any plan you are considering so you can anticipate your drug costs.

How much of my drug costs will be covered if I'm on Medicare?

If you have a Medicare Part D plan to help cover the cost of your prescription drugs, the Affordable Care Act helps to lower your expenses for medicines when you are in the so-called donut hole. The donut hole is a gap in coverage that starts when you reach your plan's drug-spending limit. In 2016, once you and your plan have spent $3,310 on covered drugs, you're in the coverage gap. At that point, you have to pay the full cost of your medications. 

If you’re in the donut hole in 2016, you'll pay 45% of the cost of  brand-name drugs and 58% of the cost of generic drugs that are covered under Medicare Part D. In 2017, your share of the cost of medications while in the donut hole drops to 40% for brand-name drugs and 51% for generics. By 2020, Medicare's donut hole will close, at which point you’ll pay just 25% of both brand-name and generic drugs while in the coverage gap.

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