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Prescription Drugs

If your health plan covers prescription drugs, your doctor will usually choose medicines from a list of the drugs the plan covers. This list is called a formulary. Many drugs on the formulary are generic drugs. Generic drugs usually cost less than brand-name drugs, but they have the same basic ingredients. Beginning in 2014 most health plans will cover prescription drugs.

Prescription Drug Costs

Usually, you will pay a fee, called a co-pay or co-insurance, each time you pick up a prescription. Some drugs may have higher co-pays than other drugs. Ask your health plan if you can order prescriptions by mail. They almost always cost less, and you can usually get a 3-month supply at a time.

If You Have Medicare

Medicare’s prescription drug program is called Medicare Part D. For more information, visit California Health Advocates or call your Medicare Advantage plan.

If You Cannot Get the Medicine You Want

If you need a drug that is not on your health plan's formulary, you must get your plan's approval or pay for the drug yourself. Your doctor should ask the plan for approval. In certain cases, a health plan may be required to cover a drug that is not on your plan's formulary. If your plan does not approve a drug that your doctor has prescribed, you can file a complaint with your plan. If you are not satisfied with your health plan’s decision, you can contact the Help Center.

 Some health plans require step therapy. This means that you have to try a drug that is on the formulary before you can get a drug that is not on the formulary.

Helpful Hints

  • Ask about the side effects, risks, and benefits of medicines.
  • Tell your doctor about any allergies or bad reactions you have had to any medicines.
  • Tell your doctor all the prescription drugs, over-the-counter medicines, and supplements you take.
  • Tell your doctor if a drug does not seem to be helping.
  • Talk to your pharmacist about when to take the drugs and what the side effects may be.
  • Ask to see the list of drugs your health plan covers. This list is called the formulary.
  • If a plan covers prescription drugs, it must cover prescription birth control methods.
  • Health plans must cover diabetes supplies.