ACA marketplace plans (available through Healthcare.gov or state exchanges) must cover prescription drugs as one of ten essential health benefits. All marketplace plans must cover at least one drug in every United States Pharmacopeia (USP) category and class. Drug costs vary significantly by metal level, with Bronze plans having the highest out-of-pocket drug costs and Platinum plans the lowest.
Key Facts
Check Your Specific Plan's Formulary
Coverage varies by plan. Use our formulary checker tool to look up your exact copay and restrictions.
Open Formulary CheckerSources and standards behind this page
Drug coverage in the United States is governed by published rules rather than by any one insurer's summary, and the sources below are the primary ones. They are linked so a reader can check a claim without taking this page's word for it.
- FDA Orange Book publishes the therapeutic-equivalence ratings that decide whether a generic may be substituted for a brand-name drug.
- FDA generic drug facts sets out what "generic equivalent" means and what a manufacturer must prove.
- CMS prescription drug coverage defines the rules a Medicare drug plan formulary must follow and how it may change mid-year.
- Medicare.gov drug coverage (Part D) states what a Part D plan is required to offer a member.
- CMS prescription drug appeals documents the coverage-determination and exception process when a drug is denied.
This page describes how coverage and formularies work. It is not medical advice, and a reader's own plan documents and prescriber decide what applies to them.
Frequently Asked Questions
No. While all plans must cover at least one drug per USP category, the specific drugs covered and their tier placement vary by insurer and plan. Two Silver plans from different companies may have very different formularies. Always check the specific formulary for each plan you are considering.
It depends on your specific medications. Gold and Platinum plans have lower copays but higher premiums. Silver plans with CSR subsidies (for households earning 100% to 250% of the federal poverty level) often provide the best overall value for prescription drugs. Use Healthcare.gov to enter your drugs and compare total costs.
Most marketplace plans do not cover weight loss medications, as they are not considered an essential health benefit. However, some insurers are voluntarily adding coverage for FDA-approved anti-obesity drugs with prior authorization. Check individual plan formularies during open enrollment.
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