Are My Prescriptions Covered by an ACA Plan?

What “covered” actually means

“Prescription drugs are covered” is true of ACA-compliant plans in the same way that “restaurants serve food” is true of restaurants. It tells you the category exists. It does not tell you whether the thing you need is on the menu, or what it costs.

Prescription drug coverage is one of the essential health benefit categories, so an ACA-compliant plan generally includes it. What varies — substantially — is which drugs a given plan covers, what it charges for them, and what it requires before paying. Those answers live in a document most people never open until something goes wrong at the pharmacy counter.

That document is the formulary, and reading it before you enroll is the entire game.

The formulary: how drug lists work

A formulary is the list of prescription drugs a plan covers. Plans generally organize it by drug class and by tier, and they publish it for each plan year.

Formularies are built by the plan, within applicable federal minimum standards. A plan’s formulary generally must cover at least the greater of one drug in every United States Pharmacopeia category and class, or the same number of prescription drugs in each category and class as the applicable EHB-benchmark plan, subject to additional federal and state requirements. That is a floor, not a promise that a specific medication is covered. The practical consequence for a household is simple and frequently overlooked: two plans from the same carrier, at the same metal tier, in the same county, can have different drug lists. A medication that is covered at a modest copay on one may sit on a higher tier — or off the list entirely — on another.

This is why a plan cannot be evaluated on premium and deductible alone. For a household with an ongoing prescription, the drug list can matter more than either.

Tiers and what you pay

Covered drugs are generally sorted into tiers, and the tier helps determine your cost-sharing. The structure varies by plan, but the general pattern:

• Lower tiers typically include generic medications, generally with the lowest cost-sharing.
• Middle tiers typically include preferred brand-name drugs.
• Higher tiers typically include non-preferred brand-name drugs, generally with higher cost-sharing.
• A specialty tier may apply to certain high-cost medications, and cost-sharing on that tier is frequently coinsurance — a percentage — rather than a flat copay.

That last point deserves emphasis. A copay is generally a fixed amount, while coinsurance is a percentage of the plan’s allowed amount, so the member’s share may be harder to predict in advance. For a household taking a specialty drug, the plan’s in-network out-of-pocket maximum is an important risk measure, but it is not the only figure that matters. The limit generally applies only to eligible cost-sharing for covered, in-network benefits. Premiums, non-covered medications, many out-of-network expenses, amounts above the plan’s allowed amount, and certain manufacturer-assistance or discount arrangements may be treated differently under the plan’s rules. See our guide to deductibles, copays, coinsurance, and out-of-pocket maximums.

The rules attached to a covered drug

“On the formulary” does not always mean “available on request.” Plans may attach utilization-management requirements to covered drugs:

• Prior authorization. The plan generally must approve the medication before it will be covered. Your prescriber submits the request.
• Step therapy. The plan generally expects one or more alternative medications to be tried first before it covers the requested drug.
• Quantity limits. The plan may limit the amount covered over a given period.

These requirements vary by plan and by drug, and they are shown in the formulary and the applicable plan documents. They are not obstacles to be discovered at the counter — they are line items to be read at enrollment, when you still have the option of choosing a different plan.

Does the deductible apply to prescriptions?

It depends on the plan, and this single variable can change what a year costs a household more than the premium difference between two plans.

Some plans apply a copay to prescriptions from the first fill, before the deductible is met. Others apply the deductible to some or all drug tiers first, meaning the member pays the plan’s allowed amount for the medication until the deductible is satisfied. Some plans apply a separate prescription deductible. Which structure applies is stated on the plan’s Summary of Benefits and Coverage — and for a household with a costly ongoing medication, it is one of the first things worth checking.

How to check every medication

1. List every medication in the household — not just the expensive ones, and including anyone covered on the plan.
2. Note the exact drug, dosage, and form. Coverage and tier can differ between a tablet and an extended-release version of the same medication.
3. Search each one against the specific plan’s current formulary for the applicable plan year.
4. Record the tier and any requirements — prior authorization, step therapy, quantity limits.
5. Check whether the deductible applies to that tier under that plan.
6. Repeat for each finalist plan before you enroll, and compare the results side by side.

Because formularies change, verify against the current plan year rather than a prior year’s list. Our guide to comparing Marketplace plans explains where this check fits in the wider comparison.

Pharmacy networks and mail order

Coverage of the drug is one question. Where you fill it is another.

Plans generally have pharmacy networks, and using a pharmacy outside the network may cost more or may not be covered. Some plans designate preferred pharmacies with lower cost-sharing, and many offer mail-order or home-delivery options for maintenance medications, sometimes at a lower cost for a longer supply. Whether that applies, and what it saves, depends on the plan.

If you fill prescriptions at a particular pharmacy for reasons of convenience or relationship, confirm that it participates in the plan’s pharmacy network before enrolling — the same way you would confirm a physician.

If a drug is not covered: exceptions and appeals

A medication missing from the formulary is not necessarily the end of the conversation.

When a member first encounters a coverage problem, the plan may offer a one-time refill or temporary supply while the member and prescriber review available alternatives or begin the exception process. This is not guaranteed, so the member should contact the plan promptly.

Plans generally must have a process for requesting coverage of a drug that is not on the formulary — commonly called an exception request — and expedited review may be available when the situation is urgent. The prescriber’s supporting statement is generally central. The prescriber may need to explain why covered alternatives have not been or are not expected to be effective, may cause harmful side effects, or why a quantity or utilization limit is not medically appropriate for the patient.

If the exception is approved, the plan generally treats the medication as covered under the applicable exception terms. The resulting cost-sharing may be based on a higher formulary tier, and eligible member payments generally count toward the applicable deductible and out-of-pocket limit.

If the request is denied, internal appeal rights generally apply, and external review by an independent reviewer may also be available. The specific process, deadlines, and requirements are described in the plan documents, and the plan must provide information about how to pursue the available review rights.

None of this guarantees approval. It is generally safer to select a plan that already covers an important ongoing medication than to enroll while assuming an exception will be granted.

When a formulary changes mid-year

Formularies can change during a plan year — a drug’s tier may change, a generic may become available, or a medication may be removed — subject to applicable rules and notice requirements.

Applicable federal and state rules may limit mid-year formulary changes affecting current enrollees and may require advance notice, continued access, or transition supplies in certain circumstances. Protections vary by plan, situation, and applicable law, so review the plan documents and contact the plan rather than assuming a change applies to you immediately.

If a medication you take is affected, contact the plan and ask specifically about exception, appeal, and any applicable transition or continued-access options, and speak with your prescriber about whether a covered alternative is clinically appropriate. What generally does not follow is a plan change: a formulary change ordinarily does not, by itself, create a standard Special Enrollment Period. In limited situations, the Marketplace may grant an enrollment opportunity under exceptional-circumstances, enrollment-error, or other applicable Special Enrollment Period rules, but consumers should not assume that a formulary change permits them to switch plans.

Prescriptions and plans in Florida

Florida uses the federally facilitated Marketplace through HealthCare.gov. Plan availability and service areas vary by county, and the formularies attached to plans vary along with them. Depending on your county, carriers may include Florida Blue and other Marketplace insurers, each publishing its own drug lists.

Because drug lists are plan-specific rather than carrier-specific, the practical advice mirrors the network advice: check the exact plan, for the current plan year, for every medication in your household. Our Florida ACA plans page covers what is offered across the state, and our Orlando-area health insurance page covers Central Florida specifically.

When to call a licensed Florida agent

Checking several medications against several plans is exactly the kind of tedious, high-stakes work people put off — and it is where an avoidable mistake turns into a monthly one.

A licensed agent can help research the plans available in your county, locate each plan’s current formulary, identify the listed tier and utilization-management indicators, and explain where the plan documents show the applicable prescription deductible and cost-sharing. The carrier makes the official coverage determination, and the pharmacy’s claim response reflects the member’s coverage and cost when the prescription is processed. What an agent cannot do is guarantee that a formulary will not change, or predict the outcome of an exception request — and any agent who promises either should be treated with caution. Insurance Advisors of Florida does not charge consumers an additional fee for assistance with eligible Marketplace enrollment, and using an agent does not increase the Marketplace plan’s filed premium or reduce the premium tax credit for which a household qualifies. We are a local Florida agency, and calls are handled by our Florida-based team rather than an outsourced call center. Insurance Advisors of Florida is located in Lake Mary and helps clients throughout Florida.

People also ask about prescription coverage

Are generic drugs always cheaper on my plan?

Generics generally sit on lower tiers with lower cost-sharing, but the specifics depend on the plan’s formulary and cost-sharing structure. The reliable way to know what a particular medication will cost is to check its tier on the specific plan and see how that plan charges for that tier.

Do I have to try a cheaper drug first?

You may, if the plan applies step therapy to that medication. Step therapy generally means the plan expects one or more alternatives to be tried before it covers the requested drug. If the formulary alternatives would not be as effective, would be harmful, or are otherwise not clinically appropriate, the plan’s exception process is generally the route, and the prescriber’s supporting statement is generally central to it.

Are birth control and other preventive medications covered without cost sharing?

Non-grandfathered plans generally must cover certain recommended preventive services without cost sharing when received from an in-network provider. For contraception, coverage generally must include, without cost sharing, at least one form of each FDA-approved, -granted, or -cleared contraceptive category identified in the applicable guidelines, and the plan generally must have an exceptions process to cover a medically necessary service or product without cost sharing when a provider determines it is appropriate. Plans may still apply reasonable medical management within a category, and certain employers may qualify for religious or moral exemptions or accommodations. Coverage depends on the service, the specific product, and the circumstances, so confirm the plan documents rather than assuming.

What if my medication changes during the year?

Check the new medication against your plan’s current formulary, including the tier and any requirements. If it is not covered, the exception and appeal process generally applies. A change in your prescriptions ordinarily does not, by itself, create a Special Enrollment Period to switch plans.

Does a discount card count toward my deductible?

It depends on the plan and applicable state rules. Some plans use copay-accumulator or copay-maximizer programs that exclude manufacturer-assistance amounts from the deductible and out-of-pocket maximum, while other plans or state requirements may require certain third-party assistance to count. Manufacturer copay assistance is also generally unavailable for drugs paid by federal healthcare programs such as Medicare and Medicaid. Confirm how the specific plan treats third-party assistance before assuming it will count.

Formularies, tier placement, utilization-management requirements, plan designs, and plan availability can change. Insurance Advisors of Florida cannot guarantee that any medication will be covered by a given plan, or predict the outcome of an exception request or appeal. This article is intended for educational purposes and is not medical, legal, or tax advice; medication decisions should be made with your prescriber. A licensed Florida health insurance agent can review your coverage options.