The short answer: prescription benefits differ by plan. Some cover generics only, some include brand and specialty, and some route maintenance medications through mail order. Before you enroll, check each medication you take against the plan's prescription benefit, by name. Tell us the drug and we will match you to a plan that actually covers it.
How prescription benefits differ
- Generics only. Some plans cover generic drugs and not brand-name ones.
- Brand and specialty. Some plans include brand-name and specialty medications. If you take a specialty drug, this is the line to read first.
- Mail order. Some plans route maintenance medications, the ones you take every month, through mail order.
- Limited medical plans. These pay a set amount toward a prescription, up to a cap, rather than covering everything above a deductible. If you take expensive prescriptions, tell us before you pick anything. Limited medical vs. major medical.
Each plan card on our site states exactly what its prescription benefit covers, including whether specialty medications are included.
Picture it
You find a plan with a lower monthly price and a deductible you can live with, and you enroll. The first month, you hand your usual prescription to the pharmacy and the price on the screen is nothing like what you paid before. The plan covers generics only, and yours is a brand-name drug.
Now picture the other version. Before you apply, you send us the name of every medication you take, with the dose. We check each one against the prescription benefit of the plans that fit you, private and Marketplace. The plan you pick is one that covers what you take, and the first pharmacy visit is uneventful.
The list to send before you enroll
- Every medication by name. Including the ones you take every month and anything you fill only now and then.
- Whether it is brand or generic. If you are not sure, the label or your pharmacy can tell you.
- Your doctors. We check them against the network at the same time. Doctor left the network?
When a plan changes at renewal, the same two checks apply: are your doctors in the new network, and are your prescriptions on the new drug list.
Medications and private plan applications
Private plans can be more affordable for healthy people and enroll any month, and they ask health questions, including about your medications. Answer every question fully and accurately; approval is the carrier's decision. Have a health condition? Tell us first: depending on the condition, a private plan may still be an option. What private plan health questions ask.
Put the medication in the yearly cost
A medication you take every month is care you already see coming, so add it to the yearly total for each plan, next to the premium. The cheapest monthly price is not always the cheapest year. Compare plans by real yearly cost.
This is general education, not medical or tax advice and not a guarantee of coverage. Prescription benefits, drug lists and pricing depend on the plan, the carrier, your state and underwriting, and can change.