How to Check If Your Medication Is Covered — and What It Will Cost

If you take prescription medications, it is important to check whether the health plan you are considering covers them and what your out-of-pocket costs may be.

Summary of Benefits (SBC)

This is a simplified overview of what a plan covers and what you can expect to pay. It includes:

• Deductible

  • Certain plans may include a distinct medication deductible, which is the amount you are required to pay out of pocket before the insurance plan starts covering the costs of prescription medications.

• Copay or coinsurance 

  • The amount you are responsible for paying, which may apply either before or after you have met your deductible depending on the medication tier. 
• Any further restrictions or limitations can be found in the far right column of the Summary of Benefits (SBC).

Drug Formulary

A drug formulary is essentially a comprehensive list of prescription medications that are covered by your insurance plan. This list provides key information, including:

• The classification of the drug as either generic or brand-name
• The specific tier designation of the drug, which directly impacts your out-of-pocket costs
• Any applicable restrictions, such as:
  • Prior authorization requirements
  • Step therapy protocols
  • Quantity limits for prescriptions

How to Check If Your Prescription Is Covered and What it May Cost

• Click on "Show more Details" to locate the Summary of Benefits and Drug Formulary
  
  

  • Click on and review the Summary of Benefits (will open in a new tab)

    • Within the SBC, scroll down to the medication section then click on the link for the drug formulary (opens a new window)

• • • • Use CTRL + F (or CMD + F on Mac) to search for your medication by name

      • The formulary will show:

        • The Tier your medication is in

        • Any restrictions (e.g., prior authorization, step therapy)

    • Return to the Summary of Benefits
      • Look for the section on prescription drug coverage
      • Find the tier to see the out-of-pocket cost for that medication

• • • • If tiers aren’t labeled, assume the first listed is Tier 1, then Tier 2, and so on
  • In the example below, Generic drugs (preferred)= Tier 1, Generic drugs (Non-Preferred) = Tier 2, and so on.