How Do Health Insurance Plans Cover Prescriptions?

Prescription drugs have become a significant part of the healthcare system in the United States. Reports show that almost 60 percent of Americans use one prescription drug each year. Even if the medication is not for long term use, you may end up needing a prescription every so often.

While prescriptions are common throughout the country, the price of them is steadily rising. The rate is actually outpacing the rate of inflation – a phenomenon that occurred in the 70s as well as the 80s. Spending on drugs is double the amount of any other industrialized nation in the world. With the price of medication, insurance is necessary to avoid the high cost. Insurance plans have been evolving over the last few decades, introducing insurance plans that do not cover prescription drugs. In fact, in 2013 only about 80 percent of insurance plans covered the cost of prescription drugs.

Healthcare Reform for Prescription Drug Coverage

With the introduction of the Affordable Care Act, each insurance plan should have covered prescription drugs to avoid medical and financial repercussions. Since 2014, the ACA has been ensuring that individuals are covered with essential health benefits, including prescription drugs.

How Do Insurance Plans Cover Prescription Costs?

There is a lot of variation in how plans work with prescription drug coverage. There are three general designs for benefits that insurance companies can use:

  • Copays may include you paying a portion while the rest is covered by your insurance without any deductibles.
  • A deductible for prescriptions is separate from the medical deductible, and copays may be applied depending on the tier level of the drug.
  • Integrated medical and prescription deductibles can be applied after the deductible is met. However, your insurance plan may have different benefits depending on the type of coverage.

There have been efforts in some states to limit the amount that individuals must pay for specialty drugs. This is to ensure that medication is affordable for individuals with conditions that require drugs that are more expensive than more common medications. If your drug is expensive, do not fret – your prescription drug insurance will pay the costs of your prescriptions if you meet your out-of-pocket maximum. At that point, prescription drugs will be fully covered for the rest of the year.

You can get the prescription you need with health insurance in the United States. Prescriptions can get expensive, so it is important to have adequate coverage. If you have trouble with making payments for your prescriptions, there are assistance programs that aid individuals and help them get the medication needed. For more information about your insurance coverage and benefits, speak with a representative that can help you understand your health insurance and discuss better options.