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Prescription Drug Coverage Under Obamacare

Here's what you need to know...
  • Obamacare guarantees ten essential health benefits in every plan sold on the exchanges
  • Prescription drug coverage is one of the ten essential benefits
  • Prescription drug coverage has qualifications for insurer options
  • Prescription drugs are an essential part of medical care
  • At least one prescription drug must be covered for every category.

Prescription drug coverage benefits are important because the alternatives are that consumers must pay out of pocket or do without needed medications. Comparison shopping is a key to getting medicines at the best rate of coverage. For some consumers, the costs of medications would interfere with medical treatment if there were not sufficient insurance payment. Compare health insurance plans now by using our FREE tool above!

Finding the Facts on your Medication

Plan providers offer extensive information about covered medications. It is often possible to research each medication in question and get an answer on the availability. The following are sources of information about covered medications.

  • Insurers website
  • The Insurer’s summary of benefits
  • Go direct to insurer online, writing, or telephone
  • Review the insurer’s literature on medication and prescription coverage

What are Prescription Drugs

Prescription drug coverage is an important part of modern medical care. For many conditions and diseases, prescription drugs are the preferred form of treatment. These are medications prescribed by a doctor and are part of a cure, like an antibiotic, or maintenance of a condition, such as pain medication. Some medications are short-term treatments while others such as for high blood pressure, might go on indefinitely. Over the counter drugs can be useful in treatment but are not covered by Obamacare although a doctor may prescribe them.

Essential Benefits Coverage

The essential benefits of prescription coverage are that it must pay some part of the costs of medications. The selected plan provides full details of the drugs that it covers. The list of covered drugs is called a formulary. When a drug of choice is not in the formulary, insurers have an exception process to reconcile the need for the drug and availability.

Coverage guaranteed

Obamacare requires plans to cover prescription drugs. The rule requires coverage of at least one prescription drug in every category. The pharmacopeia has lists of thousands of drugs.

Plan providers make up their preferred set of drugs based on costs as well as effectiveness.

While these insurer formularies often prefer generic drugs to more costly brands, the key is effectiveness. Consumers can take exception to a lower cost drug that does not seem effective.

Benchmark Plans

The ACA allows states to set the formula for drug coverage by picking a benchmark plan. The formula is the greater of one drug per category or the number of drugs by a designated benchmark plan. Many states pick a common benchmark such as the most popular small business group insurance plan. The goal of the benchmark selection is to find a starting point that has been tested in a cross section of consumers. This is an important state marketplace function.

Taking Exception to Choice of Drug

Patients can use Obamacare to process an exception when a preferred drug does not appear on an insurance provider’s formulary. Some insurers use a procedure that asks a doctor to try a lower cost generic before moving up to the brand name drug. This step up process requires that the patient finds the lower cost drug to be not effective for the intended purpose. Some insurers require a special approval for high-cost drugs when generics are also available.

Effectiveness is the key, Obamacare prescription coverage does not intend to replace uniformly higher cost drugs with lower cost generics unless they are equally effective. T

he Obamacare policy overall is to reduce costs of healthcare in the US. The quality of care is always paramount.The exception process requires a medical determination of need. The doctor certifies the necessity for the requested drug in treatment of the medical condition. Exceptions require one of the below-described criteria.

  • All other covered drugs have not been nor will not be as effective
  • Other covered drugs cause or are likely to cause undesired, harmful side effects
  • Dose allowances make the other drugs ineffective because of plan’s dose limits
  • Dose limits make the drug ineffective because of the patient’s physical make-up

Past Practices Cost More

In the past, insurers were able to avoid prescription coverages in their plans and sell a separate prescription coverage policy. The result was higher consumer costs, and for some consumers with large amounts of prescription medications, they had little choice. The costs of medications can be high and overwhelm an individual’s ability to pay. It is important to understand coverage.

Contraceptives Special Rules

Contraceptives can be covered but in some cases have been excluded from employer-sponsored plans. The federal government recognizes certain religious freedom objections from companies and permits exemptions for contraceptive medications.

Prescription Essential Benefits

The essential health benefits are a platform for improved medical care in the US. All qualified health plans sold on the federal or state Obamacare exchanges require these benefits. Prescription drugs are one of the critical points of a plan that can have particular importance to consumers. Some medical conditions require extensive use of prescription drugs to treat or control health issues. Comparison shopping can reveal strengths and weaknesses of formularies used to designate covered prescription drugs. Comparison shopping is an excellent way to compare prescription drug benefits. Start comparing health insurance plans now by entering your zip code in our FREE tool below!

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