Tip Sheet for Choosing a Plan with Good Prescription Drug Coverage

October 26, 2017

Tips for Choosing a Health Insurance Plan
with the Best Prescription Drug Coverage for You

If you are a person living with cancer or a cancer survivor making sure that the health insurance plan you choose covers the prescription drugs you need is particularly important. Open enrollment for the health insurance marketplaces runs from November 1, 2017 to December 15, 2017; your new coverage will begin January 1, 2018. This is a great opportunity to review any changes your current health insurer may make to your coverage for 2018 or to sign up for a new health insurance plan.  

As you think about the kind of health insurance coverage you or a family member needs, look carefully at the prescription drug coverage the plan offers to make sure the drugs you take will be covered.  All new health insurance plans must provide a benefit package that includes prescription drugs, but the actual drugs that are covered will vary by plan.  Because many cancer drugs can be extremely expensive, it is important to make sure that your plan covers your specific drugs.

The following are tips for how to find out about the drug coverage your plan offers.

Things You Need to Consider

Medications You Take:  The first step is to make a list of all of the prescription medications you currently are taking, including pain medication and anti-nausea drugs.  You will need this information to be able to compare the coverage offered by different insurance plans.

Drug Formularies:  Most insurance plans have a formulary – a list of the drugs the plan covers.  Check the formulary of each insurance plan you are considering to make sure that it includes the medications you are taking.  You can find out your plan’s formulary by checking their web site or calling the plan directly.

Cost Sharing:  You will want to carefully compare the cost sharing different plans charge you when you fill a prescription drug.  Some plans charge a co-pay, which is a flat rate the patient pays per prescription.  Other plans charge a coinsurance, a percent of the total cost of the drug owed by the patient.  For cancer drugs, coinsurance will almost always be more expensive than a co-pay.   

Formulary Tiers:  Plans usually divide the drugs covered into tiers or categories.  The higher the tier the more you will pay for the drug.  Many cancer drugs are on the highest tier of a plan.  You want to compare each formulary to see where your drugs fall within the plan tiers.

Appeals:  You also want to find out what kind of appeals process the plan has in place in case there are changes in the coverage of a particular drug you need or if your doctor prescribes a drug that is not on the plan’s formulary.  This is particularly important for someone living with cancer who may be taking several very expensive medications.  The information may not be available on the insurance company’s public website.  You may need to call the insurer to get this information.

How to Find the Information You Need

When you are ready to actually compare different health insurance plans to find the one that is right for you there are two helpful resources to consider:

  • www.healthcare.gov – This site includes all the information you will need in order to enroll in a health insurance plan.  You can access the information online or call the toll-free number
  • localhelp.healthcare.gov – This site will direct you to people in your community who can help answer your questions and assist you with the enrollment process.

In order to get specific information on the plan’s formulary, you will likely have to use the links on www.healthcare.gov to navigate to the plan’s website, which should have a link to the plan’s formulary.  If you need help, you can call the plan directly or call 1-800-318-2596.


ACS CAN has developed a worksheet to help you choose a plan that best meets your needs.  A copy is available at https://www.fightcancer.org/content/wp-content/uploads/2014/12/Health-Plan-Worksheet-Know-Your-Coverage-and-Costs.pdf.


For more information and additional tip sheets, please visit www.fightcancer.org/healthcare/learn.