Prescription Drug Costs and Health Reform: FAQ
Do all health plans cover prescription drugs?
Yes. All health plans for sale in your
state's Marketplace must offer prescription drug coverage. It's one
of 10 essential benefits that plans must have, according to the Affordable Care
Act.
Check the summary of benefits for plans offered by your
employer to see if it covers prescription drugs.
Are prescription drug plans the same in every state?
No. All health plans in a Marketplace must include
prescription drug coverage, but each state sets the list of covered medicines,
called the formulary. For instance, one plan may have many more medicines in
one category or class than another state does.
How do I know if a health plan will cover the medicines I
take?
Check the plan's formulary, also known as a preferred drug
list. You should be able to get this from any health plan you're
considering. Sometimes a plan's formulary will be on its web site.
The formulary lists each brand and generic name of medicines
that the plan will help pay for. To look for your medicines, you need to know:
- The
medicine's exact name
- How
many pills your doctor usually prescribes
Keep in mind that formularies can change. Medicines can be
added or removed. A generic drug can replace a brand name one. Or one
generic drug can replace another generic drug.
What if my medicine isn't on a plan's formulary?
If you can't find your medicine on a health plan's drug list
in your state's Marketplace, you can request that your plan cover it or give
you access to it.
You can request that your insurer cover a medication not on
its formulary 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 medicines?
With some health plans, you pay a coinsurance for your
medicines. This is a set percentage of the drug's cost, such as 30%. With some
health plans, you pay a prescription copay, which means you pay a fixed
amount for each medicine you buy.
Many formularies have two or more cost levels, called tiers.
The copayment for each tier will likely be different. Higher level tiers
cost you more. For instance, a third tier medicine costs more than a first tier
one.
Many health plans have three or four tiers of costs:
- Tier
1: Generic medicines, which cost the least
- Tier
2: Preferred, brand-name medicines
- Tier
3: Non-preferred, brand-name medicines
- Tier
4: Specialty medicines, which are often costly, brand-name
medicines. For instance, chemotherapy may be a fourth tier
medicine.
Keep in mind that you may have a separate deductible for
prescription drugs. You may need to pay it as well as a deductible for medical
services. Look at a plan's summary of benefits about prescription medicines to
see what you'd be responsible for paying.
After picking a health plan, how can I save money on my
medicines?
You may be able to save more money even for medicines on
your plan's formulary. Here's how:
Compare your medicine's price at local pharmacies. Some
pharmacies also have a club where you can get a discount.
Check prices on online and mail-order pharmacies. First,
make sure it’s a legitimate site. The FDA warns against the potential dangers
of buying medicine on the Internet. Some signs of a trustworthy web site
include:
- It's
licensed by the state board of pharmacy where the web site is operating.
(Look for the National Association of Boards of Pharmacy's (NABP) Verified
Internet Pharmacy Practice Sites Seal, which is also called the VIPPS
seal.)
- The
site has a licensed pharmacist available to answer your questions.
- You need
a prescription from your doctor to buy a medicine.
- There
is a phone number listed for a person you can talk to about a problem or
to ask questions.
Set up a flexible-spending account (FSA). Some
employers offer these. You determine an amount to come out of your paychecks
over the year. That amount is taken out before taxes so you can use it to pay
for health expenses, including medicines.
