Plan participants enrolled in all State health plans have prescription drug coverage available. All prescription medications are compiled on a preferred list ("formulary list") maintained by each health plan's Prescription Benefit Manager (PBM). Formulary lists categorize drugs in three levels: generic, preferred brand and nonpreferred brand.
FY13 PRESCRIPTION DRUG COPAYS & DEDUCTIBLES
Each formulary level has a different copayment amount as indicated in the chart below:
|
| |
|
QCHP
|
All Other Plans |
| |
Generic |
$11
|
$10 |
| |
Preferred Brand |
$26
|
$24 |
| |
Nonpreferred Brand |
$52
|
$48 |
| |
Deductible |
$75
|
$50 |
|
FY14 PRESCRIPTION DRUG COPAYS & DEDUCTIBLES
Each formulary level has a different copayment amount as indicated in the chart below:
|
| |
|
QCHP
|
All Other Plans |
| |
Generic |
$10
|
$8 |
| |
Preferred Brand |
$30
|
$26 |
| |
Nonpreferred Brand |
$60
|
$50 |
| |
Deductible |
$100
|
$75 |
|
Prescription Deductible
Prescriptions filled for participants enrolled in a managed care plan during FY2013 will have a $50 deductible; prescriptions filled for participants enrolled in the Quality Care Health Plan (QCHP) will have a $75 deductible.
Effective July 1, 2013, the managed care prescription deductible will be $75 and the QCHP prescription deductible will be $100 per plan participant.
Note: If the cost of the drug is less than the plan's copayment, the plan participant will pay the entire cost of the drug, all of which will be applied toward the deductible.
FY13 Prescription Deductible Example 1 – Generic Drug Cost - Total Cost is $50 or Less
| |
Total Cost of Drug |
Deductible Applied |
Deductible Remaining |
Co-payment |
Total Payment |
| QCHP First Fill |
$50 |
$50 |
$25 |
$0 |
$50 |
| QCHP Next Fill |
$50 |
$25 |
$0 |
$11 |
$36 |
| Managed Care First Fill |
$37 |
$37 |
$13 |
$0 |
$37 |
| Managed Care Next Fill |
$37 |
$13 |
$0 |
$10 |
$23 |
FY13 Prescription Deductible Example 2 – Generic Drug Cost – Total Cost is More than $50
| |
Total Cost of Drug |
Deductible Applied |
Deductible Remaining |
Co-payment |
Total Payment |
| QCHP First Fill |
$100 |
$75 |
$0 |
$11 |
$86 |
| QCHP Next Fill |
$100 |
$0 |
$0 |
$11 |
$11 |
| Managed Care First Fill |
$100 |
$50 |
$0 |
$10 |
$60 |
| Managed Care Next Fill |
$100 |
$0 |
$0 |
$10 |
$10 |
Coverage for specific drugs may vary depending upon the health plan. It is important to note that formulary lists are subject to change any time during the plan year. To compare formulary lists (preferred drug lists), cost-savings programs and to obtain a list of pharmacies that participate in the various health plan networks, plan participants should visit the website of each health plan. Certain health plans notify plan participants by mail when a prescribed medication they are currently taking is reclassified into a different formulary list category. Plan participants should consult with their physician to determine if a change in prescription is appropriate.