Large group plans andself-insured plansare not required to cover the ACA’s essential health benefits other thanpreventive care.
However, the vast majority of these plans do provide prescription drug coverage.
Formularies
The formulary is the list of drugs that your health plan will cover.
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Top-tier drugs tend to be specialty drugs, including injectables andbiologics.
For these drugs, the consumer will usually have to pay a coinsurance.
One example is insulin.
Every plan must cover rapid-acting insulin.
The same concept applies to contraception.
Restrictions
Most formularies have procedures to limit or restrict certain medications.
And out-of-pocket exposure under Part D will be further reduced starting in 2025.
These changes are a result of the Inflation Reduction Act, which was enacted in 2022.
Prescription drugs are covered by Medicaid in every state, with recipients paying either a small copay or nothing.
Insurance companies, pharmacies, drug manufacturers, or advocacy/membership organizations such as AARP can offer these plans.
Stand-Alone Drug Coverage
Prescription drug insurance is available as a stand-alone plan.
The most well-known throw in of stand-alone plan is Medicare Part D, though privately-run plans do exist.
Plans are often offered by chain pharmacies and drug manufacturers.
On a discount plan, you’ll get a certain percentage discount, similar to using a coupon.
You may pay a monthly or annual fee and receive a card to present to your pharmacist.
Some plans, like Refill Wise, are free to use but only good at certain pharmacies.
If you need a prescription that is expensive, check the manufacturers website for a drug discount plan.
Some coupons are only available for usewithoutinsurance, while others may cover the copay or coinsurance cost.
Even with a discount plan, you may still pay a considerable amount for high-cost drugs.
Summary
Most health plans in the U.S. have integrated prescription drug coverage.
Medicaid also includes prescription drug coverage.
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