Prescription Drugs

Nearly all health plans cover medically necessary prescription drugs. Health plans usually have a list of drugs they have already approved for coverage. This list is called a formulary. Health plans often place drugs into different drug tiers on the formulary. Health plans must post their formulary online. Your out-of-pocket cost for drugs will vary based on if the medication is on your health plan's formulary and, if so, what drug tier the medication is in.

Prescription Drug Costs

Usually, you will pay a fee, called a co-payment or co-insurance, each time you get a prescription. Some drugs may have higher co-payment than other drugs. Some health plans offer a service where you order prescriptions by mail. This may cost you less, and you can usually get a 3-month supply at a time.

If You Have Medicare

Medicare’s prescription drug program is called Medicare Part D. For more information, visit California Health Advocates or call your Medicare plan.

If You Cannot Get the Medicine You Want

If you need a drug that is not on your health plan's formulary, you must get your plan's approval or pay for the drug yourself. Your doctor should ask the plan for approval. In certain cases, a health plan may be required to cover a drug that is not on your plan's formulary. If your plan does not approve a drug that your doctor has prescribed, you can file a complaint with your plan. If you are not satisfied with your health plan’s decision, you can contact the Help Center.

Some health plans require step therapy. This means that you have to try a drug that is on the formulary before you can get a drug that is not on the formulary. Your provider may ask  your health plan for an exception to the step therapy process. If your plan does not approve the exception, you can file a complaint with your plan. If you are not satisfied with your health plan's decision, you can contact the Help Center for assistance.

Helpful Hints

  • Review your health plan's formulary so you understand your coverage and cost sharing.
  • If a plan covers prescription drugs, it must cover prescription birth control methods. In general, health plans may not charge a deductible, copayment, or coinsurance for covered birth control methods. This does not apply to grandfathered health plans. There are very narrow exceptions for religious employers.
  • Health plans that are amended, renewed, or delivered after January 1, 2017, are required to cover up to a 12-month supply of self-administered hormonal contraceptive (birth control pills) when dispensed at one time.
  • Health plans must cover medically necessary supplies and equipment for the management and treatment of diabetes.