Enhance Health

What You Need to Know About Prescription Drug Costs And Coverage

Prescription drug costs are on the rise, making the cost of healthcare unaffordable for many Americans. Without insurance, medication costs are prohibitive. But are they really that much better with insurance?  

Short answer – yes! The right insurance plan makes all the difference. In this article, you’ll discover what you need to know about prescription drug costs and coverage. You’ll learn what your different options are, how to apply for them, and so much more. 

Keep reading, and finally gain control over your prescription drug spend.

Overview Of Prescription Insurance Coverage

Several factors can influence prescription insurance costs and coverage. 

Most health insurance plans cover at least some of the cost of prescription medications, but the degree of coverage varies from plan to plan. The type of medications you need will also impact how much is covered, as each plan will have a list of prescription medication types and brands that it covers. 

Then there’s the issue of copays and deductibles. These affect what you’ll be spending out-of-pocket, and they apply even when you have good insurance coverage. That’s why it’s so important to choose a plan that offers prescription coverage suitable for your health status and medical needs.

Types Of Prescription Insurance Coverage

Affordable Care Act (ACA) Health Insurance Plans

All ACA-compliant (Obamacare) health insurance plans include prescription drug coverage. But with four tiers of health insurance coverage plans (bronze to platinum), these levels of coverage differ. 

If you need to take medication for a chronic medical condition, always check the drug formulary of the plan that interests you. This is the list of specific medications that the plan covers.

Also check the copays, coinsurance, and prescription deductible details. 

  • Prescription copays will set a flat amount that you must pay upfront. 
  • The coinsurance figure is the percentage that you must pay before the insurer covers the rest. 
  • The prescription deductible is the amount payable before the coverage takes effect.

Your plan may include some or all of these. The amounts and percentages may differ from one plan to the next. Bronze and silver plans have lower premiums with less coverage. Gold and platinum plans cost more monthly but have wider coverage. 

Take note that prescription deductibles are not necessarily the same as medical deductibles. A deductible is the amount of money that you’ll have to pay for services each year before the insurer starts to cover the costs. 

While some policies may have one deductible that covers both medical services and prescription drugs, others can have separate amounts for these categories. Where only one deductible is listed, it generally covers both medications and medical procedures.

Medicare Drug Plan (Medicare Part D)

Medicare is the federal health insurance program for seniors and disabled people. It is divided into four parts, A to D, governing different types of health insurance. Part D covers prescription drug insurance. 

As with the ACA, private insurance companies offer various plans, meaning they may have different costs. The medication covered may also differ depending on the plan. Copayments, coinsurance, and deductibles will apply here, too.

The Benefits Of Prescription Insurance Coverage

Prescription drug insurance coverage offers many benefits. Despite monthly premiums, the costs can be much lower than without insurance. However, this is subject to your own medical needs.

If you don’t have a chronic medical condition requiring regular medication, and rarely get sick, health insurance might not benefit you as much as other people. But your situation could change, and you may find yourself needing more medications as you get older.

People with families stand to gain the most benefit. With a spouse and/or dependents to look after, you could be unable to cope with medical bills without insurance. This includes the cost of prescription drugs.

Eligibility Requirements For Prescription Insurance Coverage

Depending on which prescription insurance coverage you choose, you’ll have to meet their eligibility criteria.

For ACA Coverage

  • US citizen or legal resident
  • Over the age of 18
  • Not covered by other person’s (like a spouse or parent) insurance
  • No employer-sponsored insurance
  • Not incarcerated at the time of application

Your total household income will determine whether or not you qualify for ACA subsidies.

For Medicare Part D Coverage

  • US citizen or legal resident
  • 65 years of age and older, or disabled
  • Recipient of (or be eligible for) social security or railroad retirement benefits
  • Qualified for Medicare Part A or B coverage
  • Live in a Part D plan’s coverage area

The Cost Of Prescription Insurance Coverage

The cost of prescription insurance coverage is not the same for everyone. Your type of insurance, plan, and eligibility for subsidies will determine your monthly health insurance costs


Your monthly premium will depend on the plan you choose, the tier it’s on, and even the state you’re in. 

Monthly premiums for ACA coverage that includes prescription insurance coverage will be about $450 to $520 on average for a silver plan. 

Low-income households qualify for cost-reduction subsidies that lower upfront costs. They also receive premium tax credits that lower their premiums or give them tax breaks.

On Medicare Part D

On Medicare Part D, the average cost per month is about $48. But, like the ACA plans, your premium amount will be affected by your income. 

There are subsidies available to low-income households who qualify for Medicare Part D. 

How To Apply For Prescription Insurance Coverage

For ACA Coverage

You can apply on the official ACA marketplace website or through private insurance companies. You’ll have to apply in the Open Enrollment time frame, which runs yearly from November 1 to January 15. Exceptions are made in the case of major life events that prevented you from meeting this rule.

Low-income households who have a total net income of 100- 400% of the federal poverty level for their state, may apply for one of the ACA’s subsidies. 

You will still need to choose a plan that meets your needs, and there are many to choose from. So if you get confused while sifting through all the jargon-filled plans, there’s a simpler solution for you.

Here at Enhance Health, we have years of experience in the health insurance industry. We can help you find a plan that covers your prescription drug costs and other medical needs at an affordable cost. We make health insurance sign-up simple! 

For Medicare Part D Coverage

Medicare Part D coverage is easy to apply for if you are already receiving social security benefits. Simply visit your local social security office, or call the Medicare helpline. If you are not receiving social security benefits yet, but are eligible, you may also apply for them online.

Like ACA plans, there’s an enrollment period for Medicare Part D. The Medicare Open Enrollment Period runs from October 15 to December 7. If you apply outside of the enrollment period but don’t qualify for a special exemption, you may face a late enrollment penalty.

Low-income households may qualify for the Part D Low Income Subsidy (LIS/Extra Help).

We are also able to assist with Medicare enrollment.

How To File A Claim For Prescription Insurance Coverage

Your ACA insurance provider will have a list of requirements to meet for filing claims. You may have to provide receipts or invoices detailing the prescription drugs claimed. 

In the case of Medicare Part D, you may also need to provide pharmacy receipts. 

Healthcare facilities and pharmacies on the network often process claims automatically. Your insurer will provide further information on the claims process in the policy document.

How To Appeal A Denied Claim For Prescription Insurance Coverage

If your claim for prescription insurance coverage is denied, you may appeal this decision. 

Appealing An ACA Plan Denial Of Coverage

There are several reasons why your insurer may deny your claim. For example, it could be that you have opted for a drug that is not the recommended drug for your condition or that you’ve chosen an alternative treatment that is not approved for medical use.

If you feel that your prescribed drug should be covered, you need to take it up with your insurer. You may appeal any claims that are denied with no just or obvious cause. You will find appeal information for ACA policies on the ACA website. 

Appealing A Medicare Denial Of Coverage 

Medicare plans will have lists of approved medications that they cover. You won’t find every drug on the market on those lists; only the commonly prescribed drugs for most medical conditions.

If Medicare has denied your prescription drug claim, you can request a ‘redetermination’ or a ‘reconsideration review’ within 60 days in writing. It would help if your primary physician confirms that a long waiting period will put your health at risk. This can speed up the process. 

If those appeal channels fail and you are still denied coverage of medication for a chronic condition, you may contact the Medicare Appeals Council (MAC).

Alternatives To Prescription Insurance Coverage

Health insurance with built-in prescription medication coverage is the best solution to increasing drug and healthcare costs. We urge you to get covered as soon as possible for long-term prescription medication savings.

If you don’t wish to apply for health insurance now or are waiting for the next enrollment period, these alternatives could work for you short term.

Medical Cost-Sharing Programs

Private cost-sharing programs often include prescription drug coverage. However, these are not the same as insurance plans. You pay a monthly contribution. The program then pools the funds to help with members’ medical expenses like doctor visits and prescription drugs.

While these programs can be helpful in the short term for uninsured people with low medical expenses, they are not suitable for anyone with a chronic condition. 

They don’t cover as many medical situations or prescription drugs as health insurance plans do. Some don’t cover prescription drugs at all. There are usually also other limitations as to when you may tap into those pooled funds.

National Prescription Savings Programs/Discounts

Several companies and organizations throughout the US offer prescription savings cards and discounts. Major pharmacy chains across the country accept these. They can significantly reduce your medication expenses.

Keep in mind that you will still need to get a prescription from a board-certified doctor for high-schedule drugs. Without insurance to cover the cost of the doctor’s visit, you will still face high out-of-pocket expenses. 


The US is the top spender on prescription drugs, and average Americans find it difficult to keep up with surging costs. The first step in managing your prescription medication expenses is finding the right insurance plan for your needs. And we’re here to help.

Our team of qualified consultants is standing by to assist you in your search. Regardless of your financial situation or employment status, we can find a plan that works for you. Contact us today and start enjoying more affordable healthcare.

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