ACA health insurance
How ACA plans cover prescriptions: tiers, formularies and prior approval
Every ACA plan has a formulary, its list of covered drugs. Where your drug sits on the list, its tier, decides what you pay, and some drugs need approval before the plan will cover them.
How it works
- Lower tiers usually mean lower copays and higher tiers more.
- Some drugs need prior authorization, meaning your doctor must request approval first.
- Some plans require you to try a different drug first, known as step therapy.
- The list can differ between plans from the same insurer.
If your medicine is not covered
You can ask your doctor to request an exception. It is not guaranteed, so it is safer to choose a plan that covers your medicine in the first place.
Have this ready when you call
- Each medicine's exact name and dose
- How often you take each
- Your pharmacy
- Your doctor's contact information
Common questions
Can the plan change my drug's tier?
Plans update formularies, usually with notice. Check the list again at renewal.
Are generics usually in lower tiers?
Often, yes, but it depends on the plan.
Related answers
Rather talk it through?
Call 855-367-1095 and a licensed agent will go through your situation with you. There is no charge to ask, and no obligation to enroll.
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- No guaranteed eligibility, pricing, or availability
- Educational starting point
Information on this site is educational and does not guarantee eligibility, enrollment, pricing, or availability. It is not a recommendation to buy any specific plan or policy.