Insurance prescription coverage largely centers around absorbing three key medication access costs – the drug ingredient producing pharmaceutical company\u2019s list price, pharmacist dispensing fees, and physician services connected to prescription management during medical appointments. Covered risks extend even to compound drug ingredients.<\/p>\n

<\/span>Cost Sharing Constructs<\/span><\/h3>\n

While insurance subsidizes total medication expenses through premiums and claims payments, prescription plans also commonly incorporate client cost-sharing through co-pays for generic, preferred, and non-preferred brand name drugs. Annual deductibles may need meeting first before coverage initiates, excluding preventive medications exempt from deductibles under ACA protections.<\/p>\n

<\/span>Administrative Restrictions<\/span><\/h3>\n

Benefit structures also embed administrative controls through requiring prior authorizations before covering exceptionally expensive specialty pharmaceuticals, delineating testing frequency caps, limiting covered pharmacy networks, establishing maximum fills without refill approvals, and promoting utilization of internal mail order channels for chronic prescriptions.<\/p>\n

<\/span>ACA Prescription Insurance Inclusion<\/strong><\/span><\/h2>\n

Obamacare<\/p><\/div>\n

Given copious coverage exclusions permeating pre-Obamacare junk plans, adequate prescription coverage represented a key tenet during Affordable Care Act insurance exchange policy standards drafting to ensure enrollee health maintenance rather than restricted-access minimal coverage shell plans.<\/p>\n

<\/span>Essential Health Benefits<\/span><\/h3>\n

Along with ambulatory services, emergency care, hospitalization, maternity\/newborn care, mental health services and more, comprehensive ACA-compliant health plans must include prescription drug coverage meeting sufficient actuarial generosity markers as one of ten delineated Essential Health Benefits categories.<\/p>\n

<\/span>Qualified Health Plan Certification<\/span><\/h3>\n

Federal administrators explicitly forbid marketplace insurers from designing Qualified Health Plans excluding traditional prescription benefits. Qualification for selling subsidized exchange products requires embedding deductible exemptions and cost reductions specifically benefitting maintenance medications for numerous chronic conditions.<\/p>\n

<\/span>Network Equity Mandates<\/span><\/h3>\n

Not only does Obamacare mandate inclusion of pharmaceutical coverage by exchange participating carriers, but regulatory equity provisions also require offering adequate networks with sufficient regional access points. Insurers cannot geographically restrict medication availability through limited contracting.<\/p>