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Will your health plan cover the drugs you need?

Written by Diane Archer

Health plans often make it hard for people to know which drugs they cover before they sign up for the plan and even harder to find out what out-of-pocket costs will be for a particular drug. Yet, different drugs in a particular class may work better or worse for a particular person.

If you have Medicare, you should be able to find out online quite quickly whether a Part D prescription drug plan covers the anti-depressant you need.  But, a new Urban Institute study suggests that people in the health insurance exchanges may have difficulty knowing whether a health plan meets their drug needs.  

The study looked at health plan coverage of anti-depressants in five state health exchanges and found significant differences among them in drugs covered and willingness to disclose which drugs were covered. Antidepressants are the third most commonly used prescription drug. More than one in 10 Americans over 12 take them.

Out of 35 health plans studied, nine excluded more than five antidepressants from coverage and some excluded up to 15.  

Allowing the plans to list drugs they cover in whatever way they choose can make it extremely hard for people to determine whether a drug is covered. And, even when people can see a drug they take is covered, it can be hard for them to know what their out-of-pocket costs will be in advance of enrolling in a plan. People in plans that charge co-insurance for drugs are generally left in the dark.

The study recommends that the state exchanges offer direct links to easily searchable lists for each plan, make it easier for an individual to appeal the non-coverage of a drug, and monitor the process to ensure its fairness; it also recommends that out-of-pocket costs be predictable.


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