Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Prescription drugs

Which medications does my insurance cover?

Check the formulary

The list of covered generic and brand name drugs (known as the formulary) is different from plan to plan.

  • Find out which “tier” your prescription is in. Something to watch for is which group or “tier” your medications belong to on that particular formulary. A lower tier means that you will pay less, and a higher tier you will pay more.  The tier can make a big difference in how much you pay when you fill your prescription. Learn more  about how prescription drug cost sharing works.
  • Check again before you re-enroll the next year. These lists are sometimes updated each year, but may be updated on a quarterly basis.

You may receive a paper copy of your plan’s formulary but since they are updated regularly, the most current information will be on your plan’s website. Most of the time you need to log in to see the formulary. So, if you’re comparing plans, contact each plan’s customer service number to ask about specific drugs, and remember to ask about the tier.

And review your plan summary or summary of benefit and coverage

If your medication is on the formulary, you know it’s covered. But, there can be big differences in what you pay when you fill your prescription.

  • How many “tiers” or cost sharing levels does your plan have? You’ll almost always pay more when you use a brand name instead of a generic drug, but cost sharing incentives might exist within either the brand name drugs or generics. Learn more  about how prescription drug cost sharing works.
  • The type of health plan you have makes a difference. Even if a medication is covered by your plan, you may have to pay the full cost until you meet your annual deductible. Learn more about how prescription drugs are covered under different types of plans.
  • Some prescriptions may be available at no cost to you. Currently, most plans cover contraceptives at 100%. You may also be able to obtain contraceptives for a full year under one prescription fill.  Some plans provide prescriptions for certain chronic conditions for free. The Affordable Care Act has a list of “no cost share” medications. It includes some preventive statins, for example. In addition, some employer plans have no cost share for generic drugs to treat certain conditions such as diabetes, high blood pressure and heart disease. Check with your plan to know your coverage.
  • When reviewing your benefits, you may wish to note that some medications are covered under the prescription drug benefit, and others are covered under the medical benefit.  This distinction is often related to whether the medication is obtained from a pharmacy or in a medical care setting, such as directly from your doctor.  The type of benefit the medication is covered under may have a substantial impact on your cost sharing.  

In general, plans don’t cover experimental treatments or items such as herbal remedies or vitamins (except prenatal vitamins often are covered), so it’s important to check the list of exclusions in your summary of benefits and coverage document as well.


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