Covered California Prescription Drug Benefits
In the past, comparing prescription (or Rx) coverage across carriers was a tricky prospect. Every carrier, it seemed, had their own method for categorizing prescriptions and determining what was covered and what wasn’t. Fortunately, the establishment of the Affordable Care Act has paved the way for many adjustments to our healthcare system that make securing and understanding coverage much simpler. One such adjustment focuses on Rx in hopes of improving member experience.
As of January 1st 2016, all plans offered by Covered CA are required to use standardized formulary tier names and descriptions. While it may still seem daunting to understand, this is a huge step toward customers being able to compare apples to apples when shopping for a Health Plan. The tier structure is as follows:
| Tier 1 | Generic | Preferred generic drugs and certain preferred brand drugs |
| Tier 2 | Preferred brand | Preferred brand drugs or non-preferred generic drugs |
| Tier 3 | Non-preferred brand | Non-preferred brand drugs or non-preferred generic drugs |
| Tier 4 | Specialty | Very expensive preferred specialty drugs that require special handling or ongoing monitoring |
It’s important to keep in mind that while the formulary tier names and descriptions have been standardized, each carrier and health plan may still offer different levels of coverage. You’ll need to familiarize yourself with each plan and check the formulary list to determine the best fit for you and your family.
All Bronze Plans and some Silver plans have Rx deductibles. Check your plan details to find out the separate drug deductibles that may apply.
Some drug tiers will have a cap on how much the member pays for each drug. The cap is called a “maximum per script.” The cap applies each time a prescription is refilled or until the maximum out-of-pocket is reached.
Select a plan below for Rx coverage info related to that health plan.