Your Pharmacy Coverage

All ACA Marketplace plans include prescription drug coverage. However, that does not mean they cover all drugs. The following questions are designed to show you how to learn more about what your insurance covers.

Does my new insurance plan cover my current prescription?

In Order to find out which prescriptions are covered through your new Marketplace plan.
Visit your insurer's website-To review a list of prescriptions your plan covers.
See your summary of benefits and coverage Form- You can get this directly from your insurance company, or by using a link that appears in the detailed description of your plan in your Marketplace account.
Call your insurer directly-To find out what is covered. Make sure to have your plan information available. The number is available on your insurance card, the insurer's website, or the detailed plan description in your Marketplace account.
Review any coverage materials-That your plan mailed to you.

What information will I find on the prescription list?

Each brand name and generic name of medicines that the plan will help pay for are listed, In order to look for your prescription, you need to know:
  • The medicine's exact name
  • The dose you take
  • How many pills your doctor usually prescribes

What if my medicine isn't included?

You can request that your plan cover it or give you access to it. You can make this request with the help of your doctor to explain the medical need. If your request is denied, you have the right to appeal your health plan's decision.

What will I pay for my medication?

  • With some health plans, you pay a co-insurance for your medications. This is a set percentage of the drug's cost, such as 30%
  • With other health plans you pay a prescription co-pay, which means you pay a fixed amount for each medication you buy.
  • You may have a separate deductible for prescription medicines. Look at your plan's summary of benefits about prescription medications to see what you are responsible for paying.

My prescription list has tiers, what is this?

Many health plans have three or four tiers, or levels of costs:
  • Tier 1: Generic medications, which cost the least.
  • Tier 2: Preferred, brand-name medications
  • Tier 3: Non-preferred, brand name medicines.
  • Tier 4: Speciality medicines, which are often costly, brand name medicines. For example, chemotherapy may be forth tier medicine.
The co-pay for each tier may be different. Higher level tiers cost you more. For example, a third tier medicine costs more than a first tier medicine.

How can I save money on my medications?

Ask your doctor about generic medication- Many medications come in generic form but are less expensive.
Share your concern with your doctor-Make sure to let your doctor know that medication cost are an issue.They might be able to :
  • Put you on a less expensive treatment.
  • review your medication list to ensure you still need everything you are taking.
  • Give you sample(if they have them) if it might be a few weeks before you are able to purchase your medicine at the pharmacy.
Compare prices at local pharmacies-Prices vary around town, depending on your medications. Some pharmacies also have a club where you can get a discount.
Set up a flexible spending account (FSA) - Some employers offer these. You determine an amount to come out of your paychecks over the year, which is taken out before taxes. You then use this untaxed money to pay for health expenses.
Check out a prescription assistance program - Many health plans and some states have prescription assistance programs.Look on medicare.gov, NeedyMeds.org and RxAssits.org to find assistance programs.