Prescription medication coverage
Prescription medication coverage is a type of health insurance benefit that pays for prescribed drugs approved by the plan’s formulary. Most prescription plans use formularies, such as those from Aetna and Blue Cross Blue Shield, which list covered drugs by tiers with varying copayments.
Insurance typically excludes over-the-counter drugs, vitamins, and cosmetic medications like finasteride. You pay a copay or coinsurance at the pharmacy, ranging from $5 to 50% of drug cost, depending on your plan and tier; for example, generic statins often cost $10 per fill under Medicare Part D in 2023.
Prior authorization requirements may delay coverage for high-cost medications, such as Sovaldi for hepatitis C. Mail order services from companies like Express Scripts reduce costs by supplying 90-day refills for chronic condition prescriptions.
Plans often have annual prescription deductibles–Medicare Part D averaged $505 in 2023–before full coverage begins. Specialty drugs for cancer or autoimmune diseases, such as Humira or Revlimid, require higher out-of-pocket costs and restricted pharmacy networks, based on a report from YourInsurance.info.
Many insurance plans set annual limits for prescription benefits; TRICARE capped total outpatient prescription spending at $4,000 per family in 2023. Prescription drug cards identify you to pharmacies and link your purchase directly to insurer billing systems like OptumRx or CVS Caremark.
Out-of-network pharmacies may result in denied claims or much higher charges due to non-contracted pricing structures.
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See also Prescription medication insurance.