What are pharmacy benefits from an Affordable Care Act Marketplace plan?

When you’re shopping for your ACA Marketplace plan, it’s important to understand what prescriptions are covered. UnitedHealthcare Individual & Family ACA Marketplace plans offer a 30-day supply of tier 2 generic prescriptions for $5 or less.¹ But what does that mean for you? Let’s break it down.

Prescription medications are categorized into tiers, or groups of medications categorized by the cost you may pay out-of-pocket. To find your estimated out-of-pocket cost you’ll need to access your plan’s Prescription Drug List (PDL), sometimes called a formulary. A PDL or a formulary is a list of covered prescribed medications or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

You’ll find medications separated into cost levels called tiers. Select a medication in Tier 1 or Tier 2 for your lowest cost-sharing options. If your medication is in a higher tier, you may pay more.

• A brand-name drug is the name given to the medication by the company that makes the drug.
• A generic drug is chemically identical — a copy of the brand-name drug. The two are considered bioequivalent and expected to do the same thing for you. Generic medications are:
  • As effective as brand-name medications²
  • Often less expensive than brand-name medications²
  • Different than brand-name medications mainly based on inactive ingredients, the ingredients that change the consistency, color or taste — but not the chemical activity — of the drug³

Check the medications listed on the PDL to find your estimated out-of-pocket cost. Sometimes you may need a medication not listed on the PDL (these are medications are called non-formulary). Start by talking to your provider about similar medications or treatment options that may work just as well. You or your healthcare provider can also request a prior authorization or exception for your plan to cover the non-formulary medication.