Two health plans can look alike on paper and still treat your prescriptions very differently. The difference shows up at the pharmacy counter.
This guide explains the main ways plans handle prescriptions. It is general. It does not describe any specific plan.
Three ways you may pay for prescriptions
- Copay: a set dollar amount for each prescription.
- Coinsurance: a share of the drug's cost, often after you meet the deductible.
- Discount card: a lower price at the pharmacy. A discount card is not insurance. The plan doesn't pay for the drug.
Here is a made-up example. Real plans vary. Say a drug costs $180 a month.
| How you pay (example only) | What you'd pay for the made-up $180 drug |
|---|---|
| Copay plan | A set $42 copay |
| HSA plan, before the deductible | The full $180 |
| HSA plan, after the deductible | 20% coinsurance, or $36 |
| Discount card | A discounted price. The plan pays nothing. |
Example only. These are not real plan prices.
Copay plans
With a copay plan, you pay a set dollar amount for each prescription. The amount usually depends on the drug's tier, such as generic, preferred brand, non-preferred brand, or specialty.
Some plans apply the deductible to drugs first, and some don't. Plans may also need prior authorization for some drugs. A 30-day and a 90-day supply can cost different amounts.
HSA plans
An HSA-eligible plan has a higher deductible. Until you meet it, you generally pay the drug's cost yourself. After that, you often pay coinsurance. Because coinsurance is a share of the cost, you pay more when the drug costs more.
Under current law, starting in 2026, bronze and catastrophic Marketplace plans count as HSA-eligible (IRS Notice 2026-05). An HSA plan may choose to cover insulin and some other chronic-condition drugs before the deductible (IRS Notice 2019-45). A tax pro can help with HSA rules.
To learn how the account side works, see our HSA guide for the self-employed.
Plans that aren't ACA plans
Some plans that aren't ACA plans limit visits, days, or services each year, or offer drugs only through a discount card. A discount card is not insurance. These plans are not a replacement for ACA coverage. Read the limits before you choose.
How to compare plans for your prescriptions
- List every drug you take, with the dose and how often you fill it.
- Check each drug on each plan's drug list (formulary). Note its tier.
- Find out if you pay a copay or coinsurance, and whether the deductible applies first.
- Ask whether the drug benefit is insurance or only a discount card.
- Check prior authorization, 30-day vs. 90-day supply, and mail order.
- Make sure your pharmacy is in the plan's network.
Then compare plans on the full year, not just the monthly price. Our guide on how to compare health insurance plans walks through the other numbers to check.
How we can help
Daniels Health Advisors is licensed in 30+ U.S. states. We can help you check your drugs against each plan's benefits. We can't promise how a plan will cover a drug. The plan decides.
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