How do I find out which prescriptions are covered under my ACA plan?
Is there a list of prescription drugs covered by my ACA plan, and where can I find it?
Yes, your ACA-compliant health insurance plan provides a list of covered prescription drugs known as a formulary. This list outlines which medications are covered by your plan and divides them into different cost-sharing tiers, which will determine how much you pay out-of-pocket. Knowing where to find your plan’s formulary is important to ensure that your medications are covered. Here’s how to locate and understand your plan’s prescription drug coverage:
1. What Is a Formulary?
A formulary is a list of the prescription drugs covered by your ACA health insurance plan. The drugs are typically organized into tiers, with each tier representing a different level of coverage and cost:
Tier 1 (Generic Drugs): The least expensive drugs, usually generics.
Tier 2 (Preferred Brand-Name Drugs): Brand-name drugs that your insurance plan prefers, often at a moderate cost.
Tier 3 (Non-Preferred Brand-Name Drugs): Higher-cost brand-name medications.
Tier 4 (Specialty Drugs): High-cost medications, often used to treat complex or rare conditions.
The formulary also includes information on whether any medications have restrictions (such as prior authorization or step therapy) and other details that affect coverage.
2. How Do I Find the List of Covered Prescription Drugs?
There are several ways to find the formulary for your ACA plan:
A. Insurance Provider’s Website
Most insurance companies offer an online, searchable formulary on their websites. You can look up specific medications by name to see if they are covered and what tier they are in.
To find the formulary, visit your insurance company’s website, navigate to the prescription drug coverage section, and search for your medication.
B. ACA Marketplace Website
If you’re shopping for or enrolled in an ACA plan through the ACA Marketplace, you can often review the plan’s formulary during the comparison process. You can search by plan and download the formulary from the plan’s details page.
C. Call Your Insurance Provider
If you prefer, you can contact your insurance provider’s customer service and ask for assistance in locating the formulary or confirming if a specific medication is covered.
D. Review Your Plan Documents
Your Summary of Benefits and Coverage (SBC) or your plan handbook may include a link to the formulary or provide instructions on how to access it online.
3. What Information Is in the Formulary?
When you review your plan’s formulary, you’ll find important information about your prescription drug coverage:
Drug Tier: Your medication will be placed in one of the formulary tiers, which impacts how much you will pay. Lower-tier medications (like generics) typically cost less than higher-tier medications (like brand-name or specialty drugs).
Cost-Sharing: The formulary will specify the copayments or coinsurance for each drug tier, showing how much you will pay for each medication.
Restrictions: Some drugs may have specific rules, such as requiring prior authorization (approval from your insurer before the drug is covered), step therapy (trying less expensive alternatives first), or quantity limits (restrictions on how much you can receive at one time).
4. What If My Medication Isn’t Covered?
If your medication is not listed in the formulary, you still have options:
Request a Formulary Exception: You or your doctor can request an exception, asking your insurance company to cover a drug that is not normally included.
Check for Generic or Alternative Drugs: Talk to your doctor about whether a lower-tier medication or generic alternative could work for you.
Appeal the Decision: If your formulary exception is denied, you have the right to appeal the decision and ask your insurance company to reconsider.
5. Pharmacy Networks
In addition to the formulary, check your plan’s pharmacy network to make sure your prescriptions are filled at an in-network pharmacy, which will minimize your out-of-pocket costs. Using an out-of-network pharmacy may result in higher costs or no coverage at all.
Key Takeaways:
Your ACA plan’s formulary lists the prescription drugs that are covered, and you can find it on your insurer’s website, the ACA Marketplace, or by contacting your insurance provider.
Medications are categorized into tiers, which determine how much you will pay out-of-pocket.
If a medication you need is not covered, you can request a formulary exception or explore alternative options with your doctor.
For help finding your plan’s formulary or understanding your prescription drug coverage, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
