A Pharmacist’s Checklist Before You Pick a Health Plan
Most families pick a health plan by looking at the monthly premium and the deductible, then hoping for the best. If someone in your house takes a medication every day, that is not enough. This health plan checklist walks you through what to check before you sign up for 2027, so the plan you choose actually works at the pharmacy counter in January.
The quick answer
Before you choose a work or marketplace plan, write down every daily medication in your household. Then, for each plan you are considering, look up every drug on the plan’s drug list, note its tier and any restrictions, and find out what you will actually pay for it each month. Add that to the premium. A plan with a low premium can cost more over the year if your family’s prescriptions land on a high tier or sit behind a big deductible.
As a pharmacist, I see the fallout every January: a refill that went smoothly for years suddenly needs paperwork, or costs three times as much. Almost all of it can be caught during open enrollment with about an hour of homework.
Know your deadline
- Marketplace plans (HealthCare.gov): Open enrollment for 2027 coverage runs November 1, 2026 through January 15, 2027. Enroll by December 15 for coverage that starts January 1. If you enroll December 16 through January 15, coverage starts February 1.
- State exchanges: Some states run their own marketplace and may set different dates. Check your state’s site.
- Employer plans: Your company sets its own enrollment window, and it is often only a few weeks long. Ask HR or check your benefits portal for the exact dates.
Step by step: how to use this checklist
- Make your medication list. Gather every prescription bottle in the house, or print a medication history from your pharmacy. Write down the drug name, strength, how often it is filled, and who takes it.
- Narrow your choices to two or three plans. Comparing ten plans at once is how important details get missed.
- Get each plan’s documents. You want the Summary of Benefits and Coverage (SBC), the drug list (also called a formulary), and the provider and pharmacy directories. The SBC is a standard, easy-to-read summary designed so you can compare plans side by side. You should get one when you shop for coverage on your own or through work, and you can ask the insurance company for one.
- Work through the checklist below for each plan. Use one copy per plan.
- Add it up. Twelve months of premiums plus your best estimate of yearly drug and doctor costs gives you a much truer picture than the premium alone.
The health plan checklist for families on daily meds
Screenshot or print this section. Fill out one copy for each plan you are comparing.
1. Your medications
- Every daily medication for every family member is on my list, including inhalers, insulin, and other injectables.
- Each drug is on this plan’s drug list (formulary). I checked the exact name and strength.
- I wrote down the tier for each drug. Tiers set your price: lower tiers usually cost less, specialty tiers usually cost the most.
- If a brand-name drug is not covered, I noted whether a generic or another covered option exists, so I can ask the prescriber about it.
2. Restrictions on each drug
- Prior authorization (PA): Does the plan need approval from your doctor before it will pay?
- Step therapy: Does the plan require you to try a different drug first?
- Quantity limits: Does the plan cap how much you can fill at a time, such as a 30-day supply?
- If any of these apply to a drug you already take, I asked the plan how it handles new members who are already on that drug.
3. Pharmacies
- My usual pharmacy is in network.
- I know whether the plan has “preferred” pharmacies with lower prices.
- I checked whether mail order is available, optional or required, and what a 90-day supply costs.
- For specialty drugs, I know which pharmacy the plan requires.
4. What you pay for prescriptions
- I know whether each drug has a copay (a fixed dollar amount) or coinsurance (a percentage of the drug’s cost).
- I know whether there is a separate prescription deductible, or whether drugs fall under the medical deductible.
- I know which drugs, if any, are covered before the deductible is met.
- I estimated what each drug will cost in January, when the deductible starts over.
5. The big numbers
- Monthly premium, multiplied by 12.
- Deductible: individual and family.
- Out-of-pocket maximum: individual and family. Prescription costs for covered drugs usually count toward it; premiums do not.
6. Doctors and care
- Every prescriber who writes our daily meds is in network.
- Our primary care doctors and any specialists are in network.
- I know whether we need referrals to see specialists.
7. Tax-advantaged accounts
- I know whether this plan is eligible for a Health Savings Account (HSA).
- If my employer offers a Flexible Spending Account (FSA), I know the enrollment deadline.
A few terms, in plain English
| Term | What it means for your prescriptions |
|---|---|
| Deductible | The amount you pay for covered care before the plan starts to pay. Some plans have a separate one just for drugs. |
| Copay | A fixed amount, like $20, that you pay for a covered prescription. |
| Coinsurance | A percentage of the cost, like 20%, that you pay. For an expensive drug, this can add up fast. |
| Out-of-pocket maximum | The most you pay for covered in-network care in a plan year. After you reach it, the plan pays 100% of covered benefits. Premiums do not count. |
| Formulary | The plan’s list of covered prescription drugs, also called a drug list. |
For 2027, the out-of-pocket maximum for marketplace and most other plans can be no more than $12,000 for an individual or $24,000 for a family. Many plans set theirs lower, so check the SBC.
Questions to ask the plan or HR
- “Is [drug name and strength] covered, and on which tier?”
- “Does it need prior authorization, step therapy, or have a quantity limit?”
- “If I’m already taking it, will I need a new approval when my coverage starts?”
- “Is the drug list expected to change during the year?”
- “What will a 30-day and a 90-day supply cost at my pharmacy, and by mail?”
- “Do prescriptions count toward the deductible and the out-of-pocket maximum?”
Common mistakes to avoid
- Assuming your plan stays the same. Even if you keep the same insurer, the drug list, tiers, and pharmacy network can change from year to year. Check again every open enrollment.
- Only checking one family member’s meds. The plan that is perfect for one person’s prescriptions may be costly for another’s.
- Looking up the drug, not the strength. Some plans cover one form or strength and not another.
- Ignoring January. If your drugs fall under the deductible, the first few months of the year can cost far more than the rest. Budget for it.
- Choosing on premium alone. The cheapest monthly bill is not always the cheapest year.
- Switching medications on your own to fit a plan. If a drug isn’t covered, talk to the prescriber. Any change goes through them.
When to talk to your pharmacist, doctor, or plan
Your pharmacist can print your medication history, tell you whether a generic exists, and explain what tiers and restrictions mean for drugs you already take. Bring your list and ask.
Your doctor or prescriber is the person to call if a drug you need isn’t on a plan’s list or needs prior authorization. They can tell you whether a covered option makes sense for you, or help request an exception. Every marketplace plan must have a process for asking it to cover a drug that isn’t on its list.
The plan itself (or HR) is the final word on coverage and price. Call the number in the plan materials, and write down the date, the name of the person you spoke with, and what they said.
For marketplace shopping, HealthCare.gov lets you compare plans and see their drug lists and provider directories before you enroll.
One hour with this checklist now can save a lot of surprises at the pharmacy counter next year. Print a copy for each plan and work through it together.
This article is for educational purposes only and is not medical, legal, or insurance advice. Talk with your pharmacist, doctor, or health plan before changing your medications or coverage. Some links may be affiliate links; see our disclosure.