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Drug Prescription Benefits Under The ACA

Did you ever have the issue in the past that your prescriptions were not covered under your health insurance plan? Or that they had a separate out-of-pocket maximum as well as a separate deductible? Thankfully, that has changed under the Affordable Care Act (ACA).

Now under the ACA, every health plan has to offer a coverage for prescription drugs. Also, the costs of any medication prescribed by your doctor are put towards your out-of-pocket maximum, as well as your deductible. Prescription coverage has become a part of medical coverage.

Each state has also set forth a list of medications that every plan within that state must offer. This is called the formulary. Keep in mind it specifies only the bare minimum that your health insurance must include; your health insurance plan may offer even more than this. Most formularies have tiers with different costs. As a general rule of thumb, the higher the their the higher the cost. Take a look at the tiers:

  • Tier 1: Generic medicines (least expensive)
  • Tier 2: Preferred brand-name medicines
  • Tier 3: Nonpreferred brand-name medicines
  • Tier 4: Speciality medicines, usually the priciest. For example, this is probably where chemotherapy drugs would fall.

So, keep in mind before purchasing a plan to check that the medication you need (or would prefer if you did get sick) are included. Consider if you would be alright with using generic medication if brand-names aren’t available. Also check the maximum dosage your insurance allows your doctor to prescribe you before you need to go get your refill. Less refills = more money saved for you.

Medications can be added or removed at any time, but the insurance provider is required to inform you in writing if you are to be affected by the changes. The most common changes are usually generic drugs replacing brand-name drugs, or one generic drug replacing another.

If you cannot find the prescription you need on the marketplace, don’t give up! You can always request that your plan covers it for you, and can enlist your doctor to help prove your medical need for it. However, if the provider offers the generic vs. the brand-name you want, the extended coverage will be unlikely. If your request is denied, you always have the right to appeal in a process called “The Appeals Process.”

Many Californians are overwhelmed by the task of figuring out the new affordable care acts and how to maximize the benefits for your family. As your agent, we can help. Email us at info@solidhealthinsurance.com or receive a free premium quote. We will make sure that we find you and your family an affordable health plan in California for 2016.

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