Are my prescription medications covered by insurance?
Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s formulary (approved list) will usually be less expensive for you.
All Marketplace plans (under the Affordable Care Act) cover prescription drugs. Fill any prescriptions you got from your doctor and take them as directed. Here are 3 things to know about filling prescriptions:
• You may have a prescription copayment. A copayment is the amount you owe for each prescription you fill. Copayments are usually between $0 and $50, depending on your insurance plan.
• Check with your insurance company to see if you need preauthorization (also called prior approval). Your health plan may require preauthorization for certain drugs, unless it’s an emergency.
• Different health plans allow you to get your medications from different pharmacies (called in-network pharmacies). Call your insurer or visit their website to find out which pharmacies are in their network.
Does my new insurance plan cover my prescription?
To find out which prescriptions are covered through your new Marketplace plan:
• Visit your insurer’s website to review a list of prescriptions your plan covers
• See your Summary of Benefits and Coverage, which you can get directly from your insurance company, or by using a link that appears in the detailed description of your plan in your Marketplace account.
• Call your insurer directly to find out what is covered. Have your plan information available. The number is available on your insurance card, the insurer's website, or the detailed plan description in your Marketplace account.
• Review any coverage materials that your plan mailed to you.
What do I do if I’m at the pharmacy to pick up my prescription and they say my plan no longer covers it?
Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.
If you can’t get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurance company for more information.
Generally, to get your drug covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition based on one or more of the following:
• All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re asking for
• Any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you
• If there’s a limit on the number of doses you’re allowed:
o That the allowed dosage hasn’t worked for your condition, or
o The drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what’s allowed by your plan.
If you get the exception:
• Your health plan generally will treat the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan (for example, a non-preferred brand drug).
• Any amount you pay for the drug generally will count toward your deductible and maximum out-of-pocket limits.
Can I get the non-covered drug during the exceptions process?
While you’re in the exceptions process, your plan may give you access to the requested drug until a decision is made.
My insurer denied my request for an exception. Now what do I do?
If your health insurance company won’t pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party.
Can I go to my regular pharmacy to get my medication?
Just like different health plans cover different medications, different health plans allow you to get your medications from different pharmacies (called in-network pharmacies). Call your insurance company or visit their website to find out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You can also learn if you can get your prescription delivered in the mail.
In Texas, health insurance plans, including those offered through the Marketplace under the Affordable Care Act, typically cover prescription medications, but coverage can vary based on the plan's formulary. Patients may have to pay a copayment for prescriptions, which can range from $0 to $50. It's important to check if preauthorization is required for certain medications and to use in-network pharmacies to fill prescriptions. To determine if a specific prescription is covered, individuals should consult their insurer's website, review their Summary of Benefits and Coverage, call the insurer directly, or check any coverage materials received by mail. If a medication is not covered, patients may ask their insurer about a one-time refill and can follow the insurer's drug exceptions process to potentially get the medication covered. If an exception is granted, the medication will usually be treated as covered with the applicable copayment. During the exceptions process, the plan may provide access to the non-covered drug. If an exception request is denied, patients have the right to appeal the decision. To find out if a regular pharmacy is in-network, individuals should contact their insurance company or check the insurer's website. Some plans also offer prescription delivery by mail.
