What are pharmacy benefits from an Affordable Care Act Marketplace plan?

When you’re shopping for your ACA Marketplace plan, it’s important to understand what prescriptions are covered. UnitedHealthcare Individual & Family ACA Marketplace plans offer a 30-day supply of tier 2 generic prescriptions for $5 or less. 1 But what does that mean for you? Let’s break it down.

Prescription medication tiers

Prescription medications are categorized into tiers, or groups of medications categorized by the cost you may pay out-of-pocket. To find your estimated out-of-pocket cost you’ll need to access your plan’s Prescription Drug List (PDL), sometimes called a formulary. A PDL or a formulary is a list of covered prescribed medications or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications. You’ll find medications separated into cost levels called tiers. Select a medication in Tier 1 or Tier 2 for your lowest cost-sharing options. If your medication is in a higher tier, you may pay more.

What's the difference between brand-name and generic medications?

• A brand-name drug is the name given to the medication by the company that makes the drug.
• A generic drug is chemically identical — a copy of the brand-name drug. The two are considered bioequivalent and expected to do the same thing for you. Generic medications are:
  • As effective as brand-name medications 2
  • Often less expensive than brand-name medications 2
  • Different than brand-name medications mainly based on inactive ingredients, the ingredients that change the consistency, color or taste — but not the chemical activity — of the drug 3

  Does my ACA Marketplace plan cover my prescription medications?

  Check the medications listed on the PDL to find your estimated out-of-pocket cost. Sometimes you may need a medication not listed on the PDL (these are medications are called non-formulary). Start by talking to your provider about similar medications or treatment options that may work just as well. You or your healthcare provider can also request a prior authorization or exception for your plan to cover the non-formulary medication.

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  Footnotes

  1. The following plan types do not offer $5 or less Tier 2 generic medications: Regulatory-required Standard/HSA Plans, Bronze & Silver Copay Focus Plans, and select State-Based Marketplaces (Maryland, Virginia and Washington). Pay a $5 copay or less for Tier 2 medications listed on the Prescription Drug List (formulary). Not available on all plans or in all states.
  2. Generic Drug Facts | fda.gov
  3. Generic Drugs | Clinical Pharmacy and Pharmacology | JAMA

  Disclaimers

  UnitedHealthcare Individual & Family plans medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in AL, KS, LA, MO, NJ, and TN; Optimum Choice, Inc. in MD and VA; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of Mississippi, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of South Carolina, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Oregon, Inc. in WA; and UnitedHealthcare of Wisconsin, Inc. Administrative services provided by United HealthCare Services, Inc. or its affiliates.

  The benefits described may not be offered in all plans or in all states. Some plans may require copayments, deductibles and/or coinsurance for these benefits. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, review your plan documents, call or write your insurance agent or the company, whichever is applicable. Plan specifics and benefits vary by coverage area and by plan category. Please review plan details to learn more. By responding to this offer, you agree that a representative may contact you. Some plans have more than 5 tiers. Refer to the PDL for your plan for more information.