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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 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 Part D. 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.  

If you're in the donut hole in 2014, you'll pay 47.5% of the cost of brand-name drugs and 72% of the cost of  generic drugs that are covered under Medicare Part D. In 2015, your share of the cost of medications while in the donut hole drops to 45% for brand-name drugs and 65% for generics.

By 2020, Medicare's donut hole 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.

 

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