Filling prescriptions: PPO plans
- Check the Approved Drug List for your plan (also called a "formulary") to make sure the drug you need is listed.
- You can get up to a 31-day supply of any drug on the formulary for one copay.
- Order your prescriptions from a network pharmacy to pay the lowest copays/coinsurance.
What you will pay for prescriptions
Your plan may have a prescription deductible, which is an amount you have to pay for prescriptions before the plan starts to pay. It may also have an out-of-network prescription deductible.
After the costs you pay for prescriptions meets your prescription deductible, you will pay a copayment or coinsurance for your prescriptions (unless you are on an HSA-compatible plan). The amount of your copayment or coinsurance depends on your plan, on whether the pharmacy is in-network or out-of-network, and on the type of drug (see Drug tiers, below).
In your member account, you can see your deductible balance (if you have one) and any copayments or coinsurance you'll need to pay.
"Tiers" are simply a way of grouping prescription drugs by cost and purpose. Generic drugs are the least expensive because they are not brand names. It's the difference between buying Kleenex® Tissue and other tissues; some are equivalent to brand-name products in the way they're made, and some just treat the same conditions, but they cost less, so your copay may be lower.
- "Preferred brand" drugs may cost more than a generic, but you'll often pay a lower copayment than for non-preferred brand drugs.
- "Non-preferred brand" drugs are the most costly drugs, so your copayment may be higher with these prescriptions. Ask your provider to prescribe a generic or preferred drug whenever possible.
- "Preferred specialty" drugs are generally self-administered medicines used for a chronic illness. They have special handling requirements or require special training before use.
- "Non-preferred specialty" drugs are more costly than the preferred specialty drugs. Ask your provider to prescribe a preferred specialty drug whenever possible.