Prescription medication coverage
Find out if your medication is covered.
Find out if we cover your prescription medication
Learn what's covered and how to use your benefits
Learn more about your Qualified Health Plan formulary
Our medication list, also known as a formulary, contains a detailed overview of the medications we cover, along with the copay amount for each.
Use our medication finder tool to search for drugs that we cover. Some covered medications may have requirements or limits. These are displayed in our medication finder tool, when you search for the medication.
Search 2026 Small business/individual plan medications
View 2026 QHP covered medication list
Search 2027 Small business/individual plan medications
2027 QHP covered medication list
Prior authorization
You or your provider must get approval from us before your prescription is filled.
Step therapy
In some cases, we may require you to first try a certain medication to treat your condition before another medication is covered.
Quantity limits
A limit on the amount of medication you can receive.
Specialty pharmacy
Prescriptions must be filled through our partner, Pharmacy Advantage.
The out-of-pocket costs for medications are defined by tiers. For qualified health plans, they are:
Tier 1 medications (Select Generic Medications) - FDA-approved medications that contain the same active ingredient(s), identical in concentration and strength to their brand name medication. Medications in this tier are comprised of low-cost generic medications.
Tier 2 medications (Generic and Select Brand Medications): - FDA-approved generic and brand name medications that meet rigorous quality, safety and cost-effectiveness guidelines, with a slightly higher out of pocket cost than Select Generic Medications.
Tier 3 medications (Preferred Brand): - FDA-approved brand name medications that meet rigorous quality, safety and cost-effectiveness guidelines.
Tier 4 medications (Non-preferred Brand and Generic Medications) - FDA-approved generic and brand name medications that meet rigorous quality, safety and cost-effectiveness guidelines that are considered non-preferred by us, which may also include higher cost generics.
Tier 5 medications (Preferred Specialty Medications) - Brand, generic or biosimilar medications approved by the FDA that are used to treat complex and/or chronic illnesses and required close supervision and monitoring. The medications in this category include higher-cost injectable/infusible and certain orally inhaled medications that may require prior authorization. To assure safe and quality care, these medications must be obtained by a designated/contracted specialty pharmacy.
Tier 6 medications (Non-Preferred Specialty Medications) - Brand, generic or biosimilar medications approved by the FDA that are used to treat complex and/or chronic illnesses and required close supervision and monitoring. The medications in this category include higher-cost injectable/infusible and certain orally inhaled medications that may require prior authorization. To assure safe and quality care, these medications must be obtained by a designated/contracted specialty pharmacy.
Preventive: Generic preventive prescription medications - used to prevent illnesses, diseases or other health problems — that the Affordable Care Act requires us to cover without charging you a copay or other out-of-pocket costs.
Medical medications - medications infused or administered in a provider's office or facility that are covered under your medical benefit. Some medical medications are classified as specialty medications, and we may require that they are obtained from a specialty pharmacy and co-insurance may apply. Home infusion medications are obtained from Home Infusion pharmacies. These are considered medical medications and coinsurance may apply.
Home delivery service and specialty provider service
We offer home delivery and specialty pharmacy services through Pharmacy Advantage, our contracted mail order provider. You can get up to a 90-day supply of some medications (new prescriptions or a simple refill). This saves time and money and eliminates trips to the pharmacy.