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El mercado de seguros de salud del estado de California desde 2013

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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. Covered California's standard plans use four:

Tier Drug Type Examples
Tier 1 Most generics and low-cost preferred brands Metformin, Lisinopril, Omeprazole
Tier 2 Non-preferred generics and preferred brands Eliquis, Jardiance, Ozempic
Tier 3 Non-preferred brands Brand-name drugs with lower-cost alternatives
Tier 4 Specialty Biologics, cancer drugs, HIV meds

Examples only: each plan's formulary says which tier a drug is on.

Drug Costs by Plan Type

Higher-tier plans generally have lower drug costs. These are Covered California's standard 2027 plans:

Plan (2027) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty)
Bronze 60 $20 40% up to $500 40% up to $500 40% up to $500
Silver 70 $20 $55 $15 20% up to $250
Silver 73 $20 $55 $95 20% up to $250
Silver 87 $10 $30 $50 15% up to $150
Silver 94 $3 $10 $15 10% up to $150
Gold 80 $19 $60 $90 20% up to $250
Platinum 90 $10 $25 $45 10% up to $250
Tip: Silver 73, Silver 87 and Silver 94 are for incomes at or below 250% FPL, and only on a Silver plan. Compare their costs with Gold and 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: A percentage instead of a copay, usually up to a limit per prescription
  • 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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