The Patient Protection and Affordable Care Act requires health insurance plans to cover prescription drugs. This means that prescription medications are available to health plan members for free or at a reduced charge.
Prescription Drug Formularies
A formulary is your health plan’s list of covered medications. Select your health insurance company to view its formulary.
|Health Insurance Company||Formulary||Customer Service|
|Anthem Blue Cross of California||Formulary||(855) 634-3381|
|Blue Shield of California||Formulary||(855) 836-9705|
|Health Net||Formulary||(888) 926-5133|
|Kaiser Permanente||Formulary||(800) 464-4000|
|L.A. Care Health Plan||Formulary||(855) 270-2327|
|Molina Healthcare||Formulary||(888) 858-2150|
|Oscar Health Plan of California||Formulary||(855) OSCAR-55|
|Sharp Health Plan||Formulary||(800) 359-2002|
|Valley Health Plan||Formulary||(888) 421-8444|
|Western Health Advantage||Formulary||(888) 563-2250|
Types of Prescription Drugs
All health plans through Covered California use the same names for drug tiers: Tier 1 (generic drugs), Tier 2 (preferred drugs), Tier 3 (non-preferred drugs) or Tier 4 (specialty drugs).
Generics are either copies of brand-name drugs or are brand-name drugs with patents that have expired. Brand-name and generic drugs have the same active ingredients, strength and dose. The U.S. Food and Drug Administration (FDA) requires that generic drugs meet the same high standards for purity, quality, safety and strength. They are usually less expensive than brand-name drugs.
Preferred, Non-Preferred and Specialty Drugs
Preferred drugs are usually the cheapest for the consumer and the insurance company. Non-preferred and specialty drugs are the most expensive.
Specialty drugs have a limit on how much a member will pay for a 30-day drug supply. Members with Silver 70, Gold 80 and Platinum 90 plans will be charged no more than $250 per month for one 30-day supply. Bronze 60 plan members will pay no more than $500 per 30-day supply.
Prescription Drugs Not Covered by a Health Plan
In general, you will need to ask your doctor to help you file an appeal so that your health insurance company grants you an exception. Or, ask your doctor if alternative drugs that are covered could substitute for the drug you need.
For help talking to a health insurance company, contact the Health Consumer Alliance at (888) 804-3536.
If you are having trouble with your health plan’s prescription drug options that has not been resolved by your plan, visit the Department of Managed Health Care Help Center or call (888) 466-2219.
Prescription Drug Costs
The table below shows prescription drug costs, according to metal tier, for all Covered California individual health insurance plans.
The dollar amounts are the member’s costs of copays, and the percentages are the coinsurance costs. If a drug is subject to a deductible, you must meet that deductible cost before the copay or coinsurance amount applies.
The health insurance company will pay the remainder of the cost of the covered drug once the enrollee has paid this amount toward any in-network covered health service, including prescription drugs.
Prescription drug lists are changed frequently. For the most current information, confirm coverage and out-of-pocket cost with your health plan before filling prescriptions.