Getting Medicine and Prescriptions Covered​​

Your Prescription Medicines

Health plans help pay the cost of covered prescription medicines. Insurers use a “formulary” that determines how much of the cost you’ll pay. You can find a link to your plan’s formulary in the Summary of Benefits Coverage in the “Common Medical Events” section in the row labeled “if you need drugs to treat your illness or condition.” A formulary usually has different tiers. Prescription medicines listed in one tier may cost you more than those in another tier.

Always show your pharmacy your health insurance card. Prescriptions that you pay for will count toward your annual out-of-pocket maximum.

To find out which prescriptions your plan covers:​

• ​Visit your insurer’s website to find your online health plan formulary.
• Check your insurance policy or certificate to learn more about your formulary.
• If you need help, call your insurer directly to find out what’s covered.​​​
  

Example: Categories of Prescription Drugs in a Tiered Formulary

$ Tier 1 — Generic drugs. These are lower-cost drugs.​

$$ Tier 2 — Preferred, brand-name drugs. These drugs cost more because they’re unique, and just one drug company makes them.

$$$ Tier 3 — Non-preferred, brand-name drugs. These are also brand-name drugs. But they may cost you more than other brand name drugs that treat the same condition.

$$$$ Tier 4 — Some plans u​se this tier for specialty drugs. Other plans have a separate “specialty” tier. These are high-cost drugs that treat rare or complex diseases.

It’s a good idea to talk with your providers about the best affordable medications for you, based on your plan.

If the pharmacy says that your plan doesn’t cover a prescription drug you’ve been taking, some insurers may let you refill the prescription once. That will give you time to talk with your provider about other options.

You also can ask your provider to ask your health plan for an exception. With an exception, you can get a prescription medicine that your plan doesn’t normally cover. Your health insurer might agree because:

• All other drugs the plan covers haven’t worked or won’t work as well as the drug the provider prescribed, or 
• All other drugs the plan covers have caused or could cause harmful side effects.​