How Prescription Drug Coverage Works Within Your Health Insurance Plan

Medication can play a key role in managing your health. Prescription drugs may be needed for preventive care or to treat certain illnesses and conditions. Ensuring you have affordable access to prescription medications will require you to have suitable health insurance. At Insurance Solutions USA, we guide individuals and families to ensure they have the necessary coverage.

Are Prescription Drugs Covered Under My Health Insurance?

As you’re likely aware, health insurance policies can come in many forms and coverage capabilities can vary significantly. Under the Affordable Care Act (ACA), these medications are considered an essential health benefit, meaning that plans sold through the Health Insurance Marketplace include prescription drug coverage. Additionally, most group health insurance plans, even if not ACA-compliant, can typically assist with prescription-related costs.

In other situations, you may need to verify coverage for prescriptions. Private health insurance plans are not all compliant with the ACA, meaning they may have more limited coverage. Short-term health insurance should not be relied on to cover these medications. If you get your health insurance through Medicare, you should also be aware that Original Medicare (i.e., parts A and B) do not typically cover prescriptions, but adding Medicare Part D or choosing Part C can fill this gap.

How Does Coverage Work?

Once you’ve verified that your prescriptions are covered, you should know that certain limitations may still exist. Health insurance plans typically include a prescription drug list, or formulary, defining what medications are covered. As with many covered medical products and services, you’ll likely still need to pay a copay out of pocket with covered drugs often sorted into tiers based on these costs. Generic versions are often available in less expensive tiers than their brand-name counterparts.

In some cases, your doctor may write a prescription without realizing the limitations of your plan. If you’ve been prescribed a brand-name medication not covered by your insurance, a generic version may be available. Otherwise, you may be able to request an exception with your doctor explaining why the drug in question is necessary.

We’re Here to Help

Contact the team at Insurance Solutions USA in Grapevine, Texas, today to learn more about health plans and ensure you have and understand essential prescription drug coverage.

This blog is intended for informational and educational use only. It is not exhaustive and should not be construed as legal advice. Please contact your insurance professional for further information.