Bottom Line on Pharmaceuticals covered under ObamaCare law


One of the ‘Essential Health Benefits’ that must be included in every health insurance plan according to the Affordable Care Act is prescription drug coverage. Here I will point out some basics of how it may affect your out of pocket costs. However, the variables on how each plan will handle this requirement can be complicated to understand. To figure out which plan will meet your needs, I would suggest getting some help from a place like

So here are some of the things to consider:

The first thing that is usually pointed out about prescription medication coverage is that ObamaCare closes the ‘donut hole’ for Medicare recipients by eliminating the annual maximum Medicare coverage for prescription meds.

$$ Seniors with high medication expenses will find this saves them some money.

Now for others – in the ‘old’ system, somewhere around 20% of health insurances (1 plan in 5) did not pay anything for drugs. You paid for all drugs out of your pocket. That worked to lower premiums for people who generally didn’t have much in the way of prescription drug expenses. Plans including drug coverage had higher premiums.

$$ Now everybody has to pay drug coverage premiums whether they use them or not. If you didn’t have drug coverage before, your premium will be higher now.

In the new system, just as in the old one, insurance companies do not pay for any part of your over-the-counter medication expenses – the things you can buy without a care-giver’s order.

$$ As before, OTC expenses all come out of your pocket – and do not count towards the deductible on your policy or for the ‘out of pocket’ annual maximum.

And just as before, the Affordable Care Act lets the health insurance company limit which prescription drugs are on its list of what drugs it will help pay for. However, it does say that there must be at least one drug on the list for each USP category and class. The US Department of Health and Human Services rule also says that insurances in any state may cover as many more drugs as are listed in that state’s choice of basic insurance plans.

$$ As before, expenses for drugs not on the list all come out of your pocket. They may or may not count towards the annual ‘out of pocket’ limit on your policy.

Insurance Policy

Different plans are still allowed to choose how they will share prescription drug costs with their clients, too. Some have flat rates for each kind of drug (generics or brand names) and others use a percentage of the drug’s cost. And the amount of each depends upon which level of coverage you chose. If you pay a higher premium price, your contribution for prescription medications will be lower.

$$ Depending on your health insurance policy, you may have to pay full price for all your drugs until you have reached your annual deductible.

As I said above, which plan will work best for you may be a bit complicated to figure out. Especially if you use a lot of expensive medications, you definitely need to compare plans to see which plan and which level will meet your needs best for the best price. Study it out carefully – and get some free help from the brokers at places like