What ACA plans must cover
Every ACA-compliant health plan, including plans on HealthCare.gov and state Marketplaces, must cover prescription drugs as an essential health benefit. Each plan must cover at least one drug in every category and class of medicine, or as many drugs as the benchmark plan in your state, whichever is more.
That's the minimum. Which specific drugs a plan covers, and what you pay for them, varies from plan to plan and from insurance company to insurance company.
The drug list (formulary)
Each plan publishes a formulary, the list of drugs it covers. Before you enroll, check that each of your medicines is on the list, in the form and strength you take.
Most formularies sort drugs into tiers:
| Tier | Usually includes | What you typically pay |
|---|---|---|
| Lower tiers | Generic drugs | Lowest copay |
| Middle tiers | Preferred brand-name drugs | Higher copay or coinsurance |
| Higher tiers | Non-preferred brands | More |
| Specialty tier | High-cost drugs for complex conditions | Often coinsurance (a percentage of the price) |
The exact tiers and amounts are in each plan's Summary of Benefits and Coverage and its formulary.
Deductibles, copays and coinsurance for drugs
Some plans charge a flat copay for drugs from day one. Others make you pay the full price of some drugs until you meet your deductible. Ask:
- Do drugs have their own deductible, or count toward the medical deductible?
- What's the copay or coinsurance for each of my medicines?
- Is there a lower price through mail order or a preferred pharmacy?
Your drug costs count toward the plan's yearly out-of-pocket maximum. Once you reach it, the plan pays 100% of covered care, including covered drugs, for the rest of the year.
Rules that can affect your medicine
- Prior authorization: the plan must approve the drug before it pays.
- Step therapy: you may need to try a lower-cost drug first.
- Quantity limits: a cap on how much the plan covers at a time.
If your drug isn't covered
You can ask your plan for an exception. Your doctor usually helps by explaining why you need that drug. Plans must decide a standard request within 72 hours, or within 24 hours if waiting could seriously harm your health. If the plan says no, you can ask for an independent review.
Some preventive medicines, like many forms of birth control, are covered at no cost when you use an in-network pharmacy.
Already on Medicare?
Medicare covers prescriptions through Part D plans or Medicare Advantage plans that include drug coverage. Since 2025 there's a yearly cap on what you pay out of pocket for covered Part D drugs ($2,100 in 2026; the amount is adjusted each year), and covered insulin costs no more than $35 a month. People with limited income may qualify for Extra Help. See Medicare help with costs.
How a licensed agent can help
Tell the agent the names and doses of your medicines and the pharmacy you use. The agent can check each plan's drug list, compare what you'd pay through the year, and explain any prior authorization or step therapy rules before you enroll. You can also check formularies yourself on HealthCare.gov or the insurance company's website.
Common questions
Can I switch plans if my drug isn't covered?
Usually only during Open Enrollment or a Special Enrollment Period. That's why it's worth checking your drugs before you enroll.
Does a discount card count toward my deductible?
Usually not. Prices paid with a discount card generally don't count toward your plan's deductible or out-of-pocket maximum. See prescription discount cards.
Last reviewed October 2026. Rules can change and can vary by state; this page is general information, not legal or tax advice.