QUESTION

One of the reasons I chose my health plan was because my prescription drugs are covered. Can my health plan make changes to what is covered once I’ve enrolled, and how will I know ahead of time?

Post enrollment issues | Individual Health Insurance
ANSWER

Yes, in nearly every state plans can make mid-year changes to the formulary. Some states limit the circumstances under which a drug may be removed from a formulary; for example, some states require plans to continue to cover drugs for consumers who have already been approved to take them. Other states require prior notice of formulary changes. You may want to contact your state Department of Insurance to find out what protections apply to you. See Resources, Where to Go for Help for a list of State Departments of Insurance.

Marketplace insurers must make the formulary or list of covered drugs available to consumers on their websites. Consumers should be able to easily access a health plan’s formulary on an insurer’s website without creating an account or entering a policy number to access the information. In addition, the website link to the formulary should also be included in the Summary of Benefits and Coverage, which provides information on the covered benefits and applicable cost-sharing amounts, and on the marketplace website. (45 C.F.R. § 147.200).

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues