Prescription drug coverage is the benefit within your health insurance plan that helps pay for medications prescribed by a licensed provider. Under the ACA, prescription drugs are one of the 10 Essential Health Benefits — all Marketplace plans are required to cover them, though what’s covered and how much you pay varies by plan.
Your plan’s formulary is the list of covered drugs organized into cost tiers. How much you pay for a prescription depends on:
Using a generic drug instead of a brand-name equivalent almost always saves money. Generics contain the same active ingredients and are FDA-approved as equivalent — ask your doctor or pharmacist if a generic version is available.
Mail-order pharmacies (offered by many plans) often provide 90-day supplies at a lower cost per dose than 30-day retail fills. If you take a maintenance medication regularly, ask your insurer about mail-order options.
Check your plan’s formulary before enrolling. Your insurer’s website or HealthCare.gov’s plan comparison tool has a drug search feature. Enter your medications to see which tier they fall on and what your estimated cost would be. If a medication you take isn’t listed, it may not be covered — factor that into your plan choice.
Possibly, but the rules vary by plan and drug. ACA plans must apply your drug spending toward your out-of-pocket maximum if the drug is covered. However, some plans have separate drug deductibles that must be met before cost-sharing kicks in. Manufacturer coupons and patient assistance programs can help with specialty drug costs, but check whether your plan’s out-of-pocket counting rules apply to third-party payments.
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