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Do health plans have to cover prescription drugs?

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All health plans for sale in your state's Marketplace, as well as those sold on the individual market or offered through a small employer, must have prescription drug coverage. It's one of 10 health benefits that plans must have, according to the Affordable Care Act. Large employers (those with 50 or more employees) don’t have 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.

SOURCES:

The Center for Consumer Information & Insurance Oversight, U.S. Department of Health and Human Services: "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage."

Centers for Medicare & Medicaid Services: "State Pharmaceutical Assistance Programs" and "Copayment/coinsurance in drug plans."

Consumers Union and Consumers Report: "Your Health Plan’s Formulary: The List of Preferred Prescription Drugs."

FAIR Health: "Factors to Consider When Choosing a Health Plan" and "A New Look At Flexible Spending Plans."

Health Reform GPS, Robert Wood Johnson Foundation and the Hirsh Health Law and Policy Program of the George Washington University School of Public Health and Health Services: "Update: Essential Health Benefits Final Rule."

National Conference of State Legislatures: "State Pharmaceutical Assistance Programs."

FDA: "The Possible Dangers of Buying Medicines over the Internet" and "Generic Drugs: Questions and Answers."

U.S. Bureau of Labor Statistics: "Definitions of Health Insurance Terms."

Avalere Health: "Drug Coverage in Essential Health Benefits Benchmark Plans: Formulary Analysis."

American Cancer Society: "Formularies and drug coverage."

Reviewed by Sarah Goodell on February 14, 2018

SOURCES:

The Center for Consumer Information & Insurance Oversight, U.S. Department of Health and Human Services: "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage."

Centers for Medicare & Medicaid Services: "State Pharmaceutical Assistance Programs" and "Copayment/coinsurance in drug plans."

Consumers Union and Consumers Report: "Your Health Plan’s Formulary: The List of Preferred Prescription Drugs."

FAIR Health: "Factors to Consider When Choosing a Health Plan" and "A New Look At Flexible Spending Plans."

Health Reform GPS, Robert Wood Johnson Foundation and the Hirsh Health Law and Policy Program of the George Washington University School of Public Health and Health Services: "Update: Essential Health Benefits Final Rule."

National Conference of State Legislatures: "State Pharmaceutical Assistance Programs."

FDA: "The Possible Dangers of Buying Medicines over the Internet" and "Generic Drugs: Questions and Answers."

U.S. Bureau of Labor Statistics: "Definitions of Health Insurance Terms."

Avalere Health: "Drug Coverage in Essential Health Benefits Benchmark Plans: Formulary Analysis."

American Cancer Society: "Formularies and drug coverage."

Reviewed by Sarah Goodell on February 14, 2018

NEXT QUESTION:

How can I find out if a health plan will cover the medicines I take?

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