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More Resources: FAQs About Your Plan

Question 1: Will I be able to get the medicine that my doctor and I think is best for me?

Find out if the health insurance plan or pharmacy benefit manager (PBM) has a limited list of medicines it will cover (known as a formulary). If someone in your family takes medication for a chronic illness, such as high blood pressure, asthma, or high cholesterol, make sure that medicine is on the formulary before you select that plan. If it isn't, and you choose that plan, you will be expected to switch to a different medication or pay for it out-of-pocket. This is a discussion you should have with your doctor to make sure that you're taking the medication that is best for you.

Find out if the health plan has to pre-approve certain medicines before you can fill the prescription. Many plans require your doctor to get prior authorization of high cost medications before insurance will pay for them. That means your doctor or pharmacist must call the health plan or PBM for permission to give you a prescription for these medications. Some plans also require you to try a less expensive medicine first before they will pay for the one your doctor recommends. Check with your plan to understand their authorization process and restrictions to avoid a surprise when you get to the pharmacy. And be sure to learn how to appeal if insurance will not pay and you feel the medication is important for your health.

Find out how often your health plan or PBM changes its formulary. Be aware that, in most states, even though your medications may be covered at the time you choose your health plan, the health plan or PBM may change its list of approved medicines at any time throughout the year. If they choose to take your medication off the formulary, you will have to pay for the medicine yourself or switch to a medication the health insurance plan prefers. Check to see what sort of notification you will get so you can discuss changes with your doctor.