When you think of health care, you probably think of doctor visits, hospitals, and emergency care. However, another very important element in any health insurance plan is the coverage of prescription drugs. In the Affordable Care Act (ACA), also known as ObamaCare, prescription drug coverage is one of the 10 essential benefits all new health plans in the individual and small group market are required to have.

Understanding Prescription Drug Benefits 

Prescription drugs are generally powerful drugs that are used for specific illnesses, as opposed to general, “over-the-counter” medication like aspirin or ibuprofen.

Once the generic version appears on the market, the price of both the original and the generic versions can drop quickly due to competition. Because of this price difference, many health insurance drug plans charge a lower copayment for generics than for brand-name medicine. This encourages customers to choose generics, resulting in lower costs for insurance companies and plan participants. 

Most health insurance does not cover all prescription drugs equally, and some prescriptions may not be covered at all. To find out if a plan covers a particular drug, you can visit the insurer’s website, call them directly, or review the plan materials you have received. The lists of approved drugs, called formularies, are generally very specific about what medicines are covered by insurance and which are not. If you have specific drug questions, your doctor may be able to assist you. If a prescription is not covered by your insurance plan’s formulary, you will have to pay the full cost yourself, and these costs will not count toward your plan’s out-of-pocket maximum.

Appealing a Prescription Drug Coverage Decision 

There may be times when your doctor insists that you need a specific drug and it is not covered by your insurance policy. If your doctor affirms that it is medically necessary and should be covered, you can appeal your insurer’s decision.

The first step in an appeal is to go through your insurance company. Your doctor can provide documentation showing that the drug you need is the only one that is successful for you, and that alternatives are harmful or simply ineffective. If you need a larger number of doses than are covered, your doctor can send paperwork showing why this is needed. If you are granted the exception, you will likely be charged the most expensive prescription drug copayment, and payments you make will count toward your overall maximum deductible or out-of-pocket limits.

If your insurance company denies the exception, the next step is to appeal to have the decision reviewed by an independent third party. For more information about the appeals process, visit the Healthcare.gov Appealing an Insurance Company Decision site.

Health care isn’t just about injuries and doctor visits. Prescription drug needs are a very important part of any health plan, and it is vital to understand your plan’s formulary. You may be able to save money by switching to a generic version of a drug. You may also find that a needed medication isn’t covered, and you need to appeal or choose a new plan during the next enrollment period. Even if you never have an issue with drug coverage, being informed is essential to making the best health insurance decisions for you and your family.