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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 based on the type of plan you have. To see exactly what a plan covers, look at its summary of benefits and coverage.

Be aware that some plans have what you pay for medicines go toward the same deductible as other care. Other plans have a deductible specific to medicine.

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 are on Medicare Part D , the Affordable Care Act helps pay for medicines when you are in the so-called donut hole. The donut hole is a gap in coverage from Medicare. And that means you have to pay the full cost of the meds. The donut hole starts when you reach your plan's drug-spending limit.  

When you're in the donut hole, you'll get a 50% discount on brand-name drugs and a 14% discount on generic drugs that are covered under Medicare Part D. You have to pay the full cost of your drugs until you reach the plan's catastrophic coverage limit.

By 2020, Medicare's prescription drug coverage gap will end.

Is there a limit on how much my health plan will pay toward caring for my chronic illness?

No. Whether you bought insurance on your own or you got it through your job, insurance companies can no longer set yearly or lifetime limits on how much they will pay toward covered essential benefits, which include chronic disease care.

Lifetime limits have already ended. Until Jan. 1, 2014, the maximum amount a plan pays toward your care each year is $2 million. After Jan. 1, 2014, there will be no limits on annual coverage.

Will my insurance help pay for my chronic disease self-management program?

Self-management programs are covered. They are part of the essential benefits from the Affordable Care Act. Many health plans from large companies also help pay for these programs.

You may have a self-management program near you. To find one, see the National Council on Aging site and search for "chronic illness self map."

How can I find out exactly how much of my chronic illness treatments my plan covers?

To know for sure how much a plan covers, you can look at the plan's summary of benefits and coverage. This summary includes:

  • How much you'll have to pay for common medical services
  • What services aren't covered by your plan
  • Details about your prescription drug coverage

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