Covered California Prescription Drug Benefits

In the past, comparing prescription (or Rx) coverage across carriers was a tricky prospect. Every carrier, it seemed, had their own method for categorizing prescriptions and determining what was covered and what wasn’t. Fortunately, the establishment of the Affordable Care Act has paved the way for many adjustments to our healthcare system that make securing and understanding coverage much simpler. One such adjustment focuses on Rx in hopes of improving member experience.

As of January 1st 2016, all plans offered by Covered CA are required to use standardized formulary tier names and descriptions. While it may still seem daunting to understand, this is a huge step toward customers being able to compare apples to apples when shopping for a Health Plan. The tier structure is as follows:

Rx Tiers
Tier 1 Generic Most generic drugs or low-cost, preferred brand drugs
Tier 2 Preferred brand Preferred brand drugs or non-preferred generic drugs
Tier 3 Non-preferred brand Non-preferred brand drugs or non-preferred generic drugs
Tier 4 Specialty Specialty drugs or net drug cost per prescription >$600

It’s important to keep in mind that while the formulary tier names and descriptions have been standardized, each carrier and health plan may still offer different levels of coverage. You’ll need to familiarize yourself with each plan and check the formulary list to determine the best fit for you and your family.

Separate Rx Deductible on Bronze and Silver Plans

The standard bronze and silver plans have a separate Rx deductible. For the standard bronze the deductible applies to all drug tiers. The silver Rx deductible is applicable to Silver 70, Silver 73 and Silver 87 plans and applies to all drug tiers except tier 1 for generic drugs.

Rx Caps

Some drug tiers will have a cap on how much the member pays for each drug. The cap is called a “maximum per script.” The cap applies each time a prescription is refilled or until the maximum out-of-pocket is reached.

Rx Coverage on Covered California Health Plans

Select a plan below for Rx coverage info related to that health plan.

Not sure how Obamacare affects your health care plans in California? Learn how the ACA works in California, including benefits, costs and enrollment.

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