The Affordable Care Act has expanded insurance coverage for prescription drugs in the United States. Prior to the Affordable Care Act, 18% of U.S. health plans in the individual and family market did not include drug insurance.1 The Affordable Care Act’s Essential Health Benefits made drug coverage mandatory for non-grandfathered health insurance. However, the requirement for drug insurance in health plans does not require all FDA prescription medications to be covered by a health plan.
The Affordable Care Act, also known as “Obamacare,” requires only one drug per category/class be included within a health plan’s list of covered medications (i.e. the formulary).2 However, the benchmark plan selected by the state in which a consumer lives can increase that requirement on a per category/class basis. The benchmark plan for a state is a health plan selected by a state to provide specificity to the 10 Essential Health Benefit requirements.
Not necessarily. Drug coverage requirements are implemented at the level of a drug class or category. For example, your state’s benchmark plan may establish that all health plans cover at least two cholesterol-lowering drugs (known as “statins”) but that does not mean that your particular health plan will cover Lipitor. Different health plans can cover different drugs within the same drug class.
HealthPocket’s research on drug coverage documented within initial rate filings for Affordable Care Act Bronze and Silver plans found that most out-of-pocket costs increased for prescription drugs as compared to 2013 pre-reform health insurance plans with drug coverage.
Before enrolling in a new health plan, you should confirm at least three things related to drug coverage:
Costs for drugs can vary significantly among plans so it is important to add monthly drug costs (and other medical service copays) to health plan premiums when comparing health plan costs.
1 Kev Coleman. “Almost No Existing Health Plans Meet New ACA Essential Health Benefit Standards.” HealthPocket.com (March 7, 2013). /healthcare-research/infostat/few-existing-health-plans-meet-new-aca-essential-health-benefit-standards.2 See II.C.2.e “Prescription Drug Benefits” within Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation, Final Rule, 78 FR 12833 (February 25, 2013). http://federalregister.gov/a/2013-04084
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