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Prescription Drug Coverage in California

All Covered California plans include prescription drug coverage, but costs vary significantly between plans. Learn how drug tiers work and how to find the most affordable coverage for your medications.

Drug Tiers Explained

Health plans organize medications into tiers, with different costs for each:

Tier Drug Type Examples Typical Cost
Tier 1 Preferred Generic Metformin, Lisinopril, Omeprazole $5-15 copay
Tier 2 Non-preferred Generic Less common generics $15-35 copay
Tier 3 Preferred Brand Eliquis, Jardiance, Ozempic $35-75 copay
Tier 4 Non-preferred Brand Brand-name drugs with alternatives 20-40% coinsurance
Tier 5 Specialty Biologics, cancer drugs, HIV meds 20-40% coinsurance

Drug Costs by Plan Type

Higher-tier plans generally have lower drug costs:

Plan Tier Generic Preferred Brand Specialty
Bronze $15-25 $50-75 30-40%
Silver $15-20 $45-65 25-35%
Gold $10-15 $35-50 20-30%
Platinum $5-10 $25-40 15-25%
Tip: Enhanced Silver plans (for lower incomes) often have drug costs similar to Gold or Platinum.

Understanding Formularies

A formulary is the list of drugs a plan covers. Before enrolling:

  • Check your medications: Make sure your drugs are on the formulary
  • Note the tier: See which tier your medications are on
  • Look for restrictions: Some drugs require prior authorization or step therapy
  • Compare plans: The same drug may be on different tiers with different carriers
Important: Formularies can change each year. Always verify coverage during enrollment.

Ways to Save on Prescriptions

  • Ask for generics: Always ask if a generic is available
  • Use mail-order: 90-day supplies often cost less than 3 monthly fills
  • Try preferred pharmacies: Some plans have lower copays at certain pharmacies
  • Look for manufacturer coupons: Many brands offer savings cards
  • Compare plans carefully: If you take expensive medications, a higher-premium plan may save money overall
Calculate Your Total Drug Costs

For each plan you're considering:

  1. List all your medications
  2. Find each drug's tier and copay/coinsurance
  3. Multiply by 12 months
  4. Add to your annual premium
  5. Compare total costs across plans

Specialty Drug Coverage

Specialty drugs for conditions like cancer, MS, HIV, or rheumatoid arthritis can cost thousands per month. Here's what to know:

  • Usually Tier 4 or 5: Coinsurance instead of copays
  • Prior authorization required: Plan must approve before filling
  • Specialty pharmacy: Often must use a designated specialty pharmacy
  • Out-of-pocket max: Higher-tier plans have lower maximums, capping your costs
Good News: Once you hit your out-of-pocket maximum, your plan pays 100% of covered drugs for the rest of the year.

Need Help Finding the Right Plan?

Our agents can help you compare drug costs across plans and find the best coverage for your medications.

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