Prescription drugs

Like most insurance companies, Oscar covers thousands of prescription drugs. Under the Affordable Care Act (opens in new tab) (aka Obamacare), all health insurance plans sold on the health care marketplace must cover certain generic and brand-name prescription drugs as an essential health benefit. But not all drugs are covered by insurance.

Formularies, aka preferred drug lists

Your insurance company has a formulary (opens in new tab), or preferred drug list, of all the medications they cover. The formulary lists a certain maximum dose and quantity of the drug that can be prescribed and covered. It also notes any prior authorizations (opens in new tab) you need to get for certain medications. While you may be able to buy other medications that aren't on your plan's formulary, they'll be more expensive, and your insurance may not cover any of the cost.

Your insurer’s formulary can change over time, so it's always a good idea to check with your insurance company before ordering a new prescription.

Brand-name drugs vs. generic drugs

Generic drugs are multi-source medications available from multiple manufacturers. These FDA-approved drugs are made with the exact same formulation of active ingredients as brand-name drugs, meaning they have the same strength, dosage, form, and administration. But because they don’t have a brand name associated with them, they often cost significantly less. That said, there are instances where generic drugs cost more than brand-name versions. So ask your doctor to check that your medications are on your insurer’s formulary and preferably on the Tier 1 or Tier 2 list (see below) to ensure you’re getting the most affordable option (opens in new tab).

Prescription drug tiers

Drugs in a formulary are classified into three tiers that line up with the industry standard:

• Tier 1: Generic and low-cost brand-name drugs.
• Tier 2: Preferred brand-name drugs, i.e., brand-name medications that do not have a generic equivalent and are typically more expensive than Tier 1 generic drugs.
• Tier 3: Non-preferred brand-name drugs that are generally available as a less-expensive Tier 2 brand-name drug or Tier 1 generic drug. If you currently take a Tier 3 drug, it’s a good idea to ask your doctor if you can take a less expensive generic or brand-name drug on the Tier 1 or Tier 2 list.

Specialty drugs

Specialty drugs are medications that require special administration and monitoring and are used to treat what are considered to be serious, chronic medical health conditions (like immune disorders, cystic fibrosis, and cancer). With Oscar’s plans, they’re available across Tiers 1 to 3, though they’re most often classified in Tier 3. They can be both brand-name and generic. Specialty drugs have their own pricing system but are generally more expensive than all other drugs in Tiers 1 to 3. You’ll typically need to get prior authorization to get specialty drugs through your insurer.

Maintenance drugs

Maintenance prescription drugs are usually used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma, and diabetes. You may be asked to mail-order longer supplies of these drugs.

What about birth control?

Birth control is considered a preventive (opens in new tab) medication and may be covered-in-full (opens in new tab) if you take a form of birth control that is listed in your health plan's formulary. You may see them listed as Tier 0.

Can I go to my regular pharmacy to get my prescription?

Just like health insurers have in-network doctors, your insurer has in-network pharmacies as well. That means you must get your prescription drugs from in-network pharmacies in order to get your insurer’s negotiated rate and for the medications to be covered and count toward your deductible and out-of-pocket max.

What if my pharmacy says my prescription isn’t covered by my plan?

You may still be able to get your prescription through your insurer’s drug exception process. Every insurer has a different procedure and rules vary depending on the state in which you live, so contact your insurer directly for next steps.

In order for a medication to be covered by the exception process, your doctor must confirm in writing that one or more of the following applies to you:

• All drugs that are covered by the plan aren’t as effective as the drug you’re requesting.
• The alternative drug(s) proposed by your insurance may cause undesirable side effects.
• The insurer’s dosage limit for the drug doesn’t work for your condition or won’t be sufficient for you.

If you get the exception: You’ll usually pay the rate for the top tier of drugs covered by your plan. Those payments count toward your deductible and out-of-pocket max.

If you are denied a drug through the exception process: You can appeal the decision and have it reviewed by a third party.