The Curious Tale of Prescription Drugs and The Affordable Care Act

Much has been written about the Affordable Care Act (ACA, PPACA, ObamaCare) with regard to keeping your plan and keeping your doctor. For many enrollees, one of the most critical and little-known elements in choosing your ACA plan may be the prescription drugs they take.

Consider this. If you enroll in a Bronze plan (the cheapest alternative considering only premium costs), you will have the highest deductible and highest out-of-pocket limits. On the other hand, if you enroll in a Platinum plan (highest premiums), you will have the lowest deductible and the lowest out-of-pocket limits.

Simple enough so far, isn't it?

So, as a plan member, you would assume that you can continue to take your standard medications. And, since it's all part of a government-mandated benefit program, you would also assume that the same prescription drugs would be available under each plan.

You would be wrong.

An ACA plan's treatment of a particular drug is a function of whether or not that drug is in the plan's formulary. For people who prefer simpler terminology, each plan's formulary is the listing of drugs that are covered by the plan. If a drug is covered by your plan, you will get discounted (think in-network) rates and your payment for that prescription will count against your deductible and out-of-pocket maximum. If it's not covered, however, then your payments will be full retail (not discounted) and will not count against your deductible or out-of-pocket maximum.

If prescription drugs are a significant part of your annual health care costs, then that leaves you with an easy solution in choosing a plan, doesn't it? You will simply look at the plan's drug formulary, compare it to what you are taking and consider how that will affect your annual cost.

Not so fast.

I actually know something about this law. My online search capabilities are as good as the next person's. I've been to the websites of several plans that can be found on the "marketplace" and in only one case thus far have I been able to find the formulary.

Suppose I find the formulary for every plan for which I am eligible. Then, of course, I can make an intelligent buying decision, can't I?

Think again. Even if you know the formulary, there is no data that I could find telling me what the discounts are under the various plans. But, I heard from someone who said he spoke with a pharmacy benefit manager (PBM) on this topic. He said he was told that pricing may vary wildly under ACA marketplace plans..

So, you tell me. Do you now know how to make your ACA buying decisions? I don't.