Most people don’t realize how much their prescription drug costs can change just by switching plans. You might think your insurance covers your meds - until you walk up to the pharmacy counter and get hit with a $500 bill for a $200 pill. That’s not a mistake. It’s a gap in your coverage. And it’s entirely avoidable.
Is prescription drug coverage even included?
It sounds basic, but you’d be surprised how many people assume their plan includes drug coverage. Under the Affordable Care Act, all Marketplace plans must cover prescription drugs. But employer plans, short-term plans, and some Medicare Advantage plans don’t always follow the same rules. Always ask: "Is prescription drug coverage part of this plan?" If the answer isn’t a clear yes, walk away. No drug coverage means no safety net for your meds.
What’s on the formulary - and are my drugs on it?
A formulary is the list of drugs your plan agrees to cover. It’s not a suggestion. It’s a contract. If your insulin, blood pressure pill, or antidepressant isn’t on it, you’re paying full price. Don’t guess. Don’t rely on what your last plan covered. Go straight to the source: get the formulary for your plan and search for each medication by its generic and brand name. Many plans list them online, but if you can’t find it, call customer service and ask for a printed copy. Keep it. You’ll need it.
What tier is my medication on - and what does that cost?
Formularies are split into tiers. Each tier has a different price. Tier 1 is usually generic drugs - think $10 copay. Tier 2 is preferred brand names - maybe $40. Tier 3 is non-preferred brands - $100 or more. Tier 4? That’s specialty drugs. These can cost $500 to $2,000 per prescription, and you might pay 25-33% of the total cost. If you take a high-cost drug like Humira, Ozempic, or a cancer med, you’re likely in Tier 4. Ask: "What tier is my medication on?" and then ask: "What’s the exact copay or coinsurance for that tier?" Don’t settle for "it’s covered." Know the number.
Do I have to pay a deductible before coverage kicks in?
Some plans have a $0 deductible for prescriptions. Others, especially Bronze Marketplace plans, can have a $6,000 deductible - meaning you pay everything out of pocket until you hit that number. That’s not just expensive. It’s dangerous. If you need a monthly medication that costs $400, you’re paying $4,800 before your insurance helps. Ask: "Is there a prescription deductible? If so, how much?" Then calculate: if you take three prescriptions a month, how many months will it take to hit that deductible? If it’s more than two, consider a higher-tier plan.
Are there step therapy or prior authorization requirements?
Step therapy means your plan won’t cover your doctor’s first-choice drug unless you try a cheaper one first. Prior authorization means your doctor has to jump through hoops - paperwork, calls, waiting - just to get approval. Both are common. In fact, 37% of specialty drugs in Marketplace plans require step therapy. And 28% of Medicare Part D prescriptions need prior authorization. Ask: "Do any of my medications require step therapy or prior authorization?" If yes, ask: "How long does approval usually take?" If it takes weeks, you might be without meds during that time. That’s not worth the risk.
Which pharmacies can I use - and what’s the difference in cost?
Not all pharmacies are created equal. Your plan likely has a network. CVS, Walgreens, and Walmart might be in-network. Your local pharmacy? Maybe not. Out-of-network pharmacies can cost 37% more. Some plans even have preferred pharmacies that charge even less - like $5 for generics instead of $10. Ask: "Which pharmacies are in-network?" Then ask: "Is there a preferred pharmacy that lowers my copay?" If your pharmacy isn’t in-network, find one that is. Or ask if your plan offers mail-order options - many save you 20-30% on 90-day supplies.
What’s the out-of-pocket maximum for prescriptions?
This is your safety net. Once you hit this number, your plan pays 100% for covered drugs for the rest of the year. But it’s not the same as your overall medical out-of-pocket max. Some plans have a separate prescription max. For example, a Silver plan might have an $8,700 medical max, but a $4,000 prescription max. If you’re on expensive meds, this matters. Ask: "Is there a separate out-of-pocket maximum for prescription drugs? What is it?" Then add up your annual drug costs. If you’re close to hitting it, you’ll know exactly when your bills will drop.
How does this plan compare to Medicare Part D if I’m eligible?
If you’re on Medicare, you have two choices: a standalone Part D plan or a Medicare Advantage plan that includes drug coverage. Part D plans usually have more flexibility - you can switch them every year, and they often cover a wider range of drugs. Advantage plans bundle medical and drug coverage, but they lock you into a network. 68% of Advantage plans use tiered pharmacy networks; only 42% of standalone Part D plans do. Ask: "Which Part D plan covers my drugs at the lowest cost?" Use the Medicare Plan Finder. Enter your exact medications, dosages, and preferred pharmacy. Don’t trust the default recommendation. It’s often the cheapest premium, not the cheapest total cost.
What changes are coming in 2025 that affect my coverage?
Big changes are coming. Starting in 2025, Medicare Part D will have a $2,000 annual cap on out-of-pocket drug costs. Insulin will be capped at $35 per month. And the "donut hole" - that gap where you pay more - will disappear. If you’re on Medicare, this could save you $1,400 a year. But it only applies to Medicare. If you’re on a Marketplace plan, nothing changes yet. Ask: "Will any of these new rules apply to me?" If you’re on Medicare, this is your chance to shop for a better plan during Open Enrollment. If you’re not, ask: "Is my plan planning to adopt similar caps?" Some insurers are starting to match Medicare’s changes early.
What happens if I need a drug that’s not covered?
Even the best plans leave gaps. If your drug isn’t on the formulary, you have options. You can ask your doctor for a generic or alternative. You can file an exception request - your doctor writes a letter explaining why you need it. You can pay out of pocket and then apply for patient assistance programs from drugmakers. Many offer free or low-cost meds to qualifying patients. Ask: "What’s the process for requesting an exception?" and "Do you have a list of patient assistance programs for high-cost drugs?" Don’t wait until you’re out of pills. Start this conversation before you need it.
When should I review this?
Don’t wait until you’re in crisis. Review your coverage every year during Open Enrollment - November 1 to January 15 for Marketplace plans, October 15 to December 7 for Medicare. That’s your chance to switch. Even if your plan looks the same, your meds might have changed. A new generic might be on the formulary. A drug you take might have moved to a higher tier. Use the plan comparison tools on HealthCare.gov or Medicare.gov. Enter your exact medications. Run the numbers. It takes 20 minutes. And people who do that save an average of $1,147 a year.
Prescription drug coverage isn’t about what’s listed on your card. It’s about what’s in the fine print. The difference between paying $10 and $500 for a pill isn’t luck. It’s knowledge. Ask the right questions. Get the answers. And never assume.
What if my medication isn’t on the formulary?
If your drug isn’t covered, you can ask your doctor to request an exception. They’ll need to explain why a covered drug won’t work for you. You can also check if the manufacturer offers a patient assistance program - many do. Some pharmacies have discount cards. And you can pay out of pocket and apply for reimbursement later if your plan allows it.
Do all insurance plans cover the same drugs?
No. Each plan has its own formulary, and even plans from the same insurer can vary by state or employer. A drug covered by one Silver plan might be excluded from another. Always check your specific plan’s formulary - never rely on what another plan covers.
Why does my copay change every year?
Formularies are updated annually. A drug might move from Tier 2 to Tier 3, or a new generic might replace your brand-name drug. Your insurer may also change pricing based on market costs. Always review your formulary at Open Enrollment - don’t wait for a surprise at the pharmacy.
Can I switch plans if my meds aren’t covered?
Yes - during Open Enrollment. Outside of that, you can only switch if you qualify for a Special Enrollment Period - like losing other coverage, moving, or getting married. Don’t wait until you’re out of pills. Check coverage before you enroll.
What’s the difference between copay and coinsurance?
A copay is a fixed amount you pay - like $10 or $40. Coinsurance is a percentage - like 25% of the drug’s cost. For expensive specialty drugs, coinsurance can mean hundreds or thousands of dollars. Always ask which one applies to your medication.
Does Medicare Part D cover all my medications?
No. Each Part D plan has its own formulary. Some exclude certain drugs, especially newer or very expensive ones. You must check your plan’s formulary and compare it to your medications. Don’t assume your current plan will cover everything next year.
Are mail-order pharmacies better for prescriptions?
Often, yes. Many plans offer lower copays for 90-day supplies through mail-order pharmacies. You can save 20-30% compared to picking up monthly at a local pharmacy. Ask if your plan offers this option - and if it’s in-network.
What if I can’t afford my copay?
Talk to your pharmacist. Many offer discount programs. Drug manufacturers often have patient assistance programs for low-income patients. Nonprofits like NeedyMeds and RxAssist can help you find free or low-cost options. Never skip your meds because of cost - there are resources.
Can I get my drug covered if my doctor prescribes it off-label?
Sometimes. Off-label use means a drug is prescribed for a condition not officially approved by the FDA. Many plans require prior authorization for this. Your doctor must provide clinical evidence that it’s medically necessary. It’s not guaranteed, but it’s possible - especially for cancer or rare disease treatments.
How do I know if my plan is the best for my medications?
Use the plan comparison tool on HealthCare.gov or Medicare.gov. Enter your exact medications, dosages, and preferred pharmacy. The tool will show you total annual costs - premiums, deductibles, copays - for each plan. The cheapest premium isn’t always the cheapest overall. Look for the lowest total cost.
