Obamacare Prescription Medication Coverage: What You Really Need to Know

Here’s what you need to know about Obamacare medication coverage, what you should do if your insurance stopped covering a medication you need, and your options.

The COVID-19 pandemic has impacted the lives of Americans across the country. As treatment for this pandemic can be intensive, it has naturally raised a lot of questions about Obamacare. The Affordable Care Act mandated insurers to provide essential health benefits to Obamacare members, but what does that entail?

Here’s what you need to know about Obamacare medication coverage, what you should do if your insurance stopped covering a medication you need, and your options.

Are All Plans for Obamacare Medication Coverage the Same?

While the Affordable Care Act required Obamacare insurers to provide prescription drug coverage, it did not specify what drugs are offered or at what cost. What does that mean for Obamacare medication coverage?

Obamacare insurers are required to provide prescription drug and durable medical equipment coverage. Equipment that may be included in your plan provides oxygen equipment, such as nebulizers, diabetic blood testing strips, and crutches. However, the equipment and prescriptions covered and at what cost will depend on the plan that you enrolled in.

Obamacare plans are categorized into four tiers: bronze, silver, gold, or platinum. The higher-tier plans, such as platinum and gold, generally include far more coverage options than the lower-tiered plans. Out-of-pocket expenses are also different between plans and tiers. Lower tiered plans, such as bronze and silver, typically pay more in copayments and coinsurance. The difference is most notable in regards to non-generic prescription medication.

Reviewing Your Obamacare Medication Coverage

You choose your Obamacare medication coverage when you enroll. Therefore, it’s essential to familiarize yourself with your prescription and durable medical equipment benefits.

You can review the prescription benefits of your current policy in several ways, including by:

  • Reviewing your Summary of Benefits and Coverage through your marketplace account
  • Contacting your insurer directly with the phone number on the back of your insurance card
  • Visiting your insurer’s website to review their plan benefits
  • Reviewing any Obamacare medication coverage summaries your insurer mailed to you

What to Do If Your Insurance Stopped Covering a Medication

If your insurance stopped covering a medication, your options might be limited. Sometimes, an insurer will provide coverage for a similar drug or a generic brand as opposed to the brand name medication. If that’s the case, talk to your doctor about whether the covered drug may work for you.

Each Obamacare insurer has an exception process where members may request that a specific prescription be covered. This process is different for every insurer, so you will need to contact yours to learn how you can start this process. In most cases, your doctor will need to provide your insurer with a written or oral statement of why another drug won’t be as effective.

If your Obamacare insurer denies your exception request, you have the right to an appeal. Once there is a decision on your exception request, you should receive a notice from your insurer that includes information about their appeal process.

Do I Have to Use My Health Insurance for Prescriptions?

In some cases, your Obamacare medication coverage may not be the most affordable option for you. You do not need to use your health insurance for a prescription if you do not want to. You can sometimes get a prescription drug for less by not using your insurance by:  

  • Comparing prices through different pharmacies in your area
  • Obtaining coupons online, through a prescription app, or from your physician
  • Using savings that you can earn on pharmacy rewards programs

Can You Change Your Obamacare Medication Coverage?

In most states, the open enrollment period for Obamacare is over. But you can enroll in or change an Obamacare plan if you qualify for a special enrollment period. The COVID-19 pandemic has caused a lot of changes for Americans in the last few weeks and you may be eligible.

You are eligible for a special enrollment period if you have a qualifying life event, such as:

  • Losing your health insurance
  • Getting married
  • Having, adopting, or placing a foster child
  • Moved to a new home in a different county or zip code

Questions About Obamacare Medication Coverage? An Agent Can Help

Your Obamacare medication coverage depends on the plan you chose, and there are several ways that you can check your plan’s benefits. Having access to affordable healthcare is essential during this crisis, so it is important to know your benefits and options. Do you still have questions about your Obamacare medication coverage? Fiorella Insurance Agency is one of Florida’s largest licensed insurance agencies, with over 66,000 healthcare customers and rising. Contact us today to speak with an agent about your Obamacare medication options. You can also get started right away by completing the form below. It only takes about a minute to complete.

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