Prescription drug insurance

Prescription drug insurance is a type of health insurance that helps pay for prescription medications, which include drugs like insulin and antibiotics. Major carriers such as Aetna, Cigna, and UnitedHealthcare offer prescription drug coverage as part of most employer health plans and many individual plans.

The Affordable Care Act requires all Marketplace health insurance plans to cover at least one drug in every category and class listed by the U.S. Pharmacopeia.

Formularies are drug lists maintained by insurers that specify which medications receive coverage; typical formularies include generics such as metformin and brands such as Humira. Monthly premiums for stand-alone Medicare Part D prescription drug plans averaged $40.47 in 2023 according to the Centers for Medicare & Medicaid Services (CMS).

Most policies have an annual deductible, which averaged $505 for Medicare Part D in 2023, before copays or coinsurance start. Copays typically range from $1 to over $100 depending on the drug tier, with generics like lisinopril usually having lower out-of-pocket costs than specialty drugs like Enbrel, as indicated by https://yourinsurance.info.

Prior authorization requirements mean insurers sometimes require pre-approval for expensive or specialty drugs, especially biologics used for rheumatoid arthritis or cancer therapy. Prescription drug coverage often excludes cosmetic drugs, fertility drugs, and some weight loss medications, evidenced by exclusions found in Blue Cross Blue Shield formularies.

Pharmacies within insurer networks–such as CVS or Walgreens–must fill prescriptions for full benefits to apply; out-of-network fills can result in higher costs or no coverage. If you exceed your plan’s maximum benefit or enter the Medicare Part D “donut hole,” you may pay up to 25% coinsurance until catastrophic coverage starts at $7,400 out-of-pocket spending in 2023.