The Affordable Care Act requires health insurance plans to include 10 essential health benefits, one of which is prescription drug coverage. Health insurance plans cover many prescription drugs (also known as prescription medications) at various costs to the enrollee. The set of prescription drugs covered by a health insurance plan may also be called a formulary, prescription drug list, outpatient prescription drug list, or select drug list.
The table below shows where to find the prescription drug lists for each Covered California health insurance plan. To receive drugs at the policyholder price, a consumer would need to receive them through a pharmacy or a mailing program that participates in their specific health insurance plan's network. In most cases, information on participating pharmacies is also included on the health insurance plan website. If not, a consumer may call the insurance company to check whether the pharmacy is a participating pharmacy.
|Health Insurance Plan||Formulary||Customer Service|
|Anthem Blue Cross of California||Formulary||1-855-634-3381|
|Blue Shield of California||Formulary||1-800-393-6130|
|Chinese Community Health Plan||Formulary||1-888-775-7888|
|L.A. Care Health Plan||Formulary||1-800-788-2949|
|Sharp Health Plan||Formulary||1-800-359-2002|
|Valley Health Plan||Formulary||1-888-421-8444|
|Western Health Advantage||Formulary||1-800-903-8664|
Some health insurance plans refer to the "Select Drug List" or "Drug Tiers" in their formulary. The Select Drug List is a list of brand-name and generic drugs that have been approved by the U.S. Food and Drug Administration (FDA) and have been reviewed and recommended for their quality.
Some health insurance plan formularies refer to FDA Drug Tiers. Drugs on the U.S. Food and Drug Administration (FDA) Select Drug List are grouped into tiers. Several factors determine which tier a drug is placed in. These factors include:
- The cost of the drug.
- The cost of the drug in comparison to other drugs used for the same type of treatment.
- The availability of over-the-counter options.
- Other clinical and cost factors.
Prescription drug lists are changed frequently. For the most current information, a consumer should confirm coverage and out-of-pocket cost with their specific health insurance plan before filling prescriptions.
Prescription Drugs Not Covered by a Health Plan
For medications that a plan does not cover, consumers should contact their health insurance plan's customer service representative and ask specifically about the medication needed. It is important to describe the exact Covered California health insurance plan, because health insurance companies have many health insurance plans and products. If the exact medication is not available, a consumer may ask to identify substitutes and associated out-of-pocket costs.
The next option for a consumer is to ask his/her physician if any of the alternatives are a reasonable substitute for the specific situation. If not, a consumer should ask his/her physician if he or she would be willing to file an appeal to get an exception.
Health insurance plan formularies will include drug coverage for most types of conditions. For help talking to a health insurance company, contact the Health Consumer Alliance, which offers free local assistance to Covered California health insurance plan members. Visit the Health Consumer Alliance website or call (888) 804-3536.
Prescription Drug Costs
Generic drugs are the cheapest, preferred drugs are more expensive, and non-preferred brand drugs and specialty drugs are the most expensive options.
The tables below show prescription drug prices, according to metal tier, for all 2015 Covered California health insurance plans for individuals. The dollar amounts are the costs of copays, and the percentages are the coinsurance costs. If a drug is subject to a deductible, the enrollee must meet that deductible cost before the copay or coinsurance amount applies. (It is important to note that Bronze HSA plan prices differ from the Bronze information below.) Additionally, all health insurance plans have a maximum limit for out-of-pocket costs. After the consumer has reached that limit, the insurance company will pay 100 percent of the cost of the covered drug. The out-of-pocket maximums are also shown in the tables below.
2017 Prescription Drug Prices by Metal Tier
2015 Prescription Drug Prices by Metal Tier
|Preferred brand name||$50*||$50**||$50||$15|
|Non-preferred brand name||$75*||$70**||$70||$25|
|Out-of-pocket maximum (individual)||$6,250||$6,250||$6,250||$4,000|
* subject to $5,000 deductible
** subject to $250 deductible
2015 Prescription Drugs Prices for Enhanced Silver Plans
| Silver 73
(200%-250% of federal poverty level)
(150%-200% of federal poverty level)
(100%-150% of federal poverty level)
|Preferred brand name||$35*||$15**||$5|
|Non-preferred brand name||$60*||$25**||$10|
|Out-of-pocket maximum (individual)||$5,200||$2,250||$2,250|
* subject to $250 deductible
** subject to $50 deductible
Brand-name drugs have been developed by a company that holds the rights to sell them. When the rights expire, other drug companies can make a copy of the brand drugs (generics). Brand-name drugs may be more familiar to a consumer because they are advertised more frequently. Also, brand name drugs are usually more expensive than generics.
Generics are either copies of brand-name drugs, or brand-name drugs with patents that have expired. Brand-name and generic drugs have the same active ingredients, strength and dose. The U.S. Food and Drug Administration requires that generic drugs meet the same high standards for purity, quality, safety and strength. Generic drugs are almost always less expensive than brand-name drugs.
Preferred, Non-Preferred and Specialty Drugs
Health insurance plans often structure their formularies into pricing groups. Some drugs are in lower priced groups and cost consumers less money. Other drugs are in higher priced groups and cost consumers more money. Preferred drugs are usually the cheapest for the consumer and the insurance company. Non-preferred and specialty drugs are the most expensive, both for the consumer and the insurance company.