Prescription Coverage

Health plan participants (members and dependents) are required to pay a prescription deductible each plan year.

Plan participants enrolled in any of the State health plans have prescription drug coverage included in their health plan benefits. Prescription benefits are administered by the health plan's prescription benefit manager (PBM). Members who use the PBMs pharmacy network to obtain their medication will be charged the applicable prescription copayment after the prescription deductible has been met. A pharmacy that is not in the network may charge more than the copayment amount; therefore, members should verify that a pharmacy is in network in order to avoid high prescription costs.

Plan participants enrolled in HealthLink OAP, Aetna OAP, the Consumer Driven Health Plan (CDHP) or the Quality Care Health Plan (QCHP) have specific policies, as well as maintenance and nonmaintenance prescription networks they should be aware of prior to selecting a pharmacy.

New for FY21

Maintenance Choice: The Maintenance Choice tier is available to those members covered under an OAP, QCHP or CDHP. This tier allows members to obtain specific medications in a 90-day supply from a CVS Caremark® pharmacy or through the CVS Caremark® Mail Service Pharmacy for half of the copayment. Please contact CVS Caremark® to determine if your medication is available under this benefit.

Reduced Tier 1: The Reduced Tier 1 pharmacy benefit is available through an HMO carrier. This tier allows members to obtain specific medications in either a 30-day or 90-day supply for a reduction of the normal tier 1 applicable copayment.Please contact your HMO to determine if your medication is availabe under this benefit.

 

Plan participants enrolled in BlueAdvantage HMO, Health Alliance HMO, Aetna HMO and HMO Illinois may also receive a discount when they fill a 90-day supply of medication. Plan participants enrolled in one of these plans should contact their health plan for information regarding discounts and formulary lists. When enrolled in an HMO plan, a 90-day supply of medication is 2.5 times the copayment amount when ordered through the plan's mail order pharmacy. Some HMO plans also offer the 2.5 copayment discount for a 90-day supply filled at a retail pharmacy. Check with your HMO to determine if your plan offers a 90-day supply through a retail pharmacy.

Under the Affordable Care Act, Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs, will be covered by the plan without cost-sharing requirements.

Copayments and Deductibles FY19 & FY20 Plan Years
​Formulary Category (30-day supply) QCHP HMO & OAP​
​Generic​$10.00$8.00
​Preferred Brand​$30.00​$26.00
Non-Preferred Brand​​$60.00​$50.00
​Deductible$125.00$100.00


FY21 State Prescription Copayments (Effective July 1, 2020)

​​
*Reduced Tier I​
Tier I​
Tier II​
Tier III​
​​HMOs
​30-day supply
​$4.00
​$13.00
​$31.00
​$55.00
​90-day supply
​$10.00
​$32.50
​$77.50
​$137.50

​​OAPs
​30-day supply

​$13.00
​$31.00
​$55.00
​90-day supply
​$32.50
​$77.50
​$137.50
​**90-day
Maintenance Choice
​$16.25
​$38.75
​$68.75

QCHP



​30-day supply

​$15.00
​$35.00
​$65.00
​90-day supply
​$37.50
​$87.50
​$162.50
​​**90-day
Maintenance Choice

​$18.75
​$43.75
​$81.25

CDHP

​30 -day supply
​90% - Deductible Applies
​​90% - Deductible Applies
​​90% - Deductible Applies
​90-day supply
​​90% - Deductible Applies
​​90% - Deductible Applies
​90% - Deductible Applies
​​**90-day
Maintenance Choice
​​95% - Deductible Applies
​​95% - Deductible Applies
​​95% - Deductible Applies

* Applies to specific medications as defined by plan.
**Medications received at CVS Caremark® Pharmacy or through CVS Caremark® Mail Service Pharmacy


Prescription Deductible

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.
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.
 

Last Updated 05/01/2020