Your costs for covered prescription drugs
Prescription drug benefits are automatically included with medical coverage through the Board of Pensions at no additional cost. You share in the cost of medically necessary drugs prescribed for you and your enrolled family members.
Prescription drug benefits help with the cost of medications prescribed to maintain or restore health, or to treat ongoing health conditions. Your out-of-pocket cost for covered drugs varies depending on
- which medical option you are enrolled in (PPO, EPO, or HDHP);
- whether the drug is on the preventive drug list;
- the drug type (generic, formulary, or non-formulary); and
- whether you fill your prescription at a retail pharmacy or through the plan’s mail service.
If a brand-name medication is used when an equivalent generic exists, you will be responsible for the cost difference between the brand-name and the generic in addition to the applicable copay or coinsurance.
Under the HDHP, note that your annual deductible applies when filling prescriptions for covered non-preventive drugs. If you set up a health savings account (HSA), you can use funds in your HSA to help pay for out-of-pocket prescription drug costs.
For the PPO and EPO, if your employer offers a healthcare flexible spending account (FSA), you may be able to pay for out-of-pocket costs for prescriptions from your FSA.
Note: The EPO and HDHP do not cover non-formulary drugs. If you are enrolled in one of these options and you fill a prescription for a brand-name drug that is not on the formulary, you pay 100 percent of the drug cost.
How much you pay
Review prescription drug copays, coinsurance, and out-of-pocket maximum amounts for the medical option in which you are enrolled:
To calculate your out-of-pocket cost for a covered drug log on to the Express Scripts website, click Price a Medication in the menu under Prescriptions, enter the requested information, and click the Get Prices button. You can also contact Quantum Health at 855-497-1237 and a Care Coordinator can help you find and compare drug costs.
Note: The Price a Medication calculator does not imply a guarantee of coverage as covered products or categories are subject to individual plan restrictions and/or limitations.
PPO costs
| Benefit | PPO |
|---|---|
| Preventive prescription drugs generic retail (30/90 days) | $5/$15 |
| Preventive prescription drugs generic mail order (90 days) | $12.50 |
| Preventive prescription drugs formulary brand retail (30/90 days) | $20/$60 |
| Preventive prescription drugs formulary brand mail order (90 days) | $50 |
| Generic retail (30/90 days) | $10/$30 |
| Generic mail (90 days) | $25 |
| Formulary brand retail (30/90 days) | 30% of cost |
| Formulary brand mail (90 days) | 30% of cost $50 min to $250 max |
| Non-formulary brand retail (30/90 days) | 50% of cost 30 days: $50 min to $150 max 90 days: $150 min to $450 max |
| Non-formulary brand mail (90 days) | 50% of cost $125 min to $375 max |
| Specialty drugs | Same as above for formulary and non-formulary brands; no max applies for certain non-essential specialty drugs |
| Prescription out-of-pocket maximum
(excluding non-formulary brand-names and certain non-essential specialty pharmacy drugs) | $3,000 (member & family combined) |
| Medical out-of-pocket maximum | Lowest salary band: $2,200/family* Highest salary band: $4,340/family* |
| Total maximum out-of-pocket | $5,000/member; $10,000/family** |
EPO costs
| Benefit | EPO |
|---|---|
| Preventive prescription drugs generic retail (30/90 days) | $6/$18 |
| Preventive prescription drugs generic mail order (90 days) | $15 |
| Preventive prescription drugs formulary brand retail (30/90 days) | $30/$90 |
| Preventive prescription drugs formulary brand mail order (90 days) | $75 |
| Generic retail (30/90 days) | $12/$36 |
| Generic mail (90 days) | $30 |
| Formulary brand retail (30/90 days) | 35% of cost |
| Formulary brand mail (90 days) | 35% of cost $85 min to $375 max |
| Non-formulary brand retail and mail | Not covered |
| Specialty drugs | Same as above for formulary brands; no max applies for certain non-essential specialty pharmacy drugs |
| Prescription and medical out-of-pocket maximum | Part of the total maximum out-of-pocket |
Total maximum out-of-pocket | $5,000/member; $10,000/family** |
HDHP costs
| Benefit | HDHP |
|---|---|
| Preventive prescription drugs generic retail (30/90 days) | $6/$18 Not subject to HDHP deductible |
| Preventive prescription drugs generic mail order (90 days) | $15 Not subject to HDHP deductible |
| Preventive prescription drugs formulary brand retail (30/90 days) | $30/$90 Not subject to HDHP deductible |
| Preventive prescription drugs formulary brand mail order (90 days) | $75 Not subject to HDHP deductible |
| Formulary brand and generic retail (30/90 days) and mail (90 days) | Member pays 100% up to deductible amount; after deductible, member pays 30% subject to $150 (30 day), $450 (90 day), or $375 (90 day mail) max |
| Non-formulary brand retail and mail | Not covered |
| Specialty drugs | Same as above for formulary brands |
| Prescription and medical out-of-pocket maximum | Part of the total maximum out-of-pocket |
Total maximum out-of-pocket | $5,000/member; $10,000/family** |
*The medical out-of-pocket maximum is the most a PPO member will pay in a year in the form of coinsurance. It does not include copays, deductibles, or prescription drug costs.
**The total maximum out-of-pocket includes network deductibles and coinsurance; medical out-of-pocket maximum (PPO only); prescription drug out-of-pocket maximum (PPO only); copays (PPO and EPO); and prescription drug copays [certain non-essential specialty pharmacy drugs (PPO and EPO) and non-formulary brand-name drugs excluded].