Understand Your Drug Coverage in Minutes
Upload your Summary of Benefits and Coverage document. We will extract your drug cost structure and show you exactly what you will pay.
Your SBC document is processed securely and deleted immediately after analysis. No account required. No data stored beyond your 4-hour session. We never share, sell, or retain your insurance information. See our privacy policy.
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We will extract your deductible, OOP max, drug tier copays, and plan details
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Analyzing your plan structure...
Extracting deductible, OOP limits, drug tiers, and cost sharing
Your Plan Summary
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Individual Deductible
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Family Deductible
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OOP Maximum (Individual)
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OOP Maximum (Family)
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HSA Eligible
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Specialty Threshold
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Mail Order
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Drug Tier Cost Sharing
| Tier | Description | In-Network Cost |
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| No tier data extracted | ||
What is an SBC?
A Summary of Benefits and Coverage (SBC) is a standardized document that every health insurer must provide. It uses a consistent format mandated by the ACA, making it possible to compare plans and extract your drug coverage structure automatically.
Where to find your SBC:
- 1 Employer HR portal or benefits website. Look under "Plan Documents" or "Benefits Summary."
- 2 Insurance company website. Log in to your member account and check "Plan Details" or "Documents."
- 3 Healthcare.gov (Marketplace plans). Go to your application and select "Plan Details."
- 4 Ask your HR department or call the number on the back of your insurance card. They are required by law to provide it.
Frequently Asked Questions
What is a formulary?
A formulary is a list of prescription drugs covered by a health insurance plan. Plans organize drugs into tiers, with lower tiers generally having lower out-of-pocket costs. Not all drugs are on every formulary, and tier placement varies by plan.
What do drug tiers mean?
Most plans use a tier system: Tier 1 (preferred generics, lowest cost), Tier 2 (non-preferred generics or preferred brands), Tier 3 (non-preferred brands, higher cost), Tier 4 or 5 (specialty drugs, highest cost). Your copay or coinsurance depends on which tier your drug is placed on.
What is prior authorization?
Prior authorization (PA) is a requirement from your insurance plan that your doctor must get approval before the plan will cover a specific drug. The plan reviews whether the drug is medically necessary based on your diagnosis, treatment history, and their clinical criteria.
What is step therapy?
Step therapy requires you to try one or more less expensive drugs before your plan will cover a more expensive drug. For example, a plan might require you to try metformin before covering a GLP-1 drug like Ozempic. Your doctor can request an exception if there is a clinical reason to skip a step.
How do I know if my drug is covered by my plan?
Check your plan's formulary, which lists all covered drugs and their tier placement. You can usually find it on your insurance company's website. InsureWith.ai aggregates formulary data from Medicare Part D, ACA Marketplace plans, and major commercial insurers so you can search across plans in one place.
What should I do if my drug is denied coverage?
First, ask your doctor for the specific denial reason. Common paths forward: request a formulary exception from your plan (your doctor submits a letter of medical necessity), appeal the denial through your plan's formal appeals process, ask your doctor about therapeutic alternatives that are on formulary, or check if the drug manufacturer offers a patient assistance program.
What is the difference between a copay and coinsurance?
A copay is a fixed dollar amount you pay for a prescription (e.g., $10 for a generic). Coinsurance is a percentage of the drug's cost (e.g., 20% of a $500 specialty drug = $100). Plans may use copays for lower tiers and coinsurance for higher tiers and specialty drugs.
How often does formulary data change?
Plans can update their formularies throughout the year. Major changes typically happen at the start of the plan year (January for Medicare, plan renewal date for employer plans). Mid-year changes are less common but can occur. CMS requires Part D plans to provide 60 days notice before removing a drug or moving it to a less favorable tier.