Prescription drug
Your medication costs vary based on your medical plan and whether you use generic, preferred brand, non-preferred brand or specialty drugs and whether you fill your prescriptions with an in-network or out-of-network pharmacy. Using generic and preferred brands will ensure the best rates for your prescription needs.
If you enroll in medical coverage, you are automatically enrolled in prescription drug coverage.
Prescription drug benefit
If you enroll in one of the BCBS medical plans, the prescription drug benefits will be administered by Optum Rx.
| Plan features | BCBS HRA/Optum Rx | BCBS HSA/Optum Rx | BCBS PPO/Optum Rx | |||
|---|---|---|---|---|---|---|
| In-network | Out-of-network | In-network | Out-of-network | In-network | Out-of-network | |
| 30-day supply through retail or mail order | ||||||
| Preventive* | No copay | 50% after deductible | 0%, no deductible | 50% after deductible | No copay | 50% |
| Generic | $15 copay | 50% after deductible | 25% after deductible | 50% after deductible | $15 copay | 50% |
| Preferred brand | 30% up to $125 max | 50% after deductible | 30% after deductible (up to $125 max) |
50% after deductible | $30 copay | 50% |
| Non-preferred brand | 40% up to $225 max | 50% after deductible | 40% after deductible (up to $225 max) |
50% after deductible | $60 copay | 50% |
| Specialty (limited to a 30-day supply) |
40% up to $225 max | 50% after deductible | 40% after deductible (up to $225 max) |
50% after deductible | $80 copay | 50% |
| 90-day supply through retail or mail order (Note: Mail order is not covered out-of-network.)** | ||||||
| Preventive | No copay | 50% after deductible | 0%, no deductible | 50% after deductible | No copay | 50% |
| Generic | $37 copay | 50% after deductible | 25% after deductible | 50% after deductible | $37 copay | 50% |
| Preferred brand | 30% up to $312 max | 50% after deductible | 30% after deductible (up to $312 max) | 50% after deductible | $75 copay | 50% |
| Non-preferred brand | 40% up to $562 max | 50% after deductible | 40% after deductible (up to $562 max) | 50% after deductible | $150 copay | 50% |
*You can obtain specific preventive medications in-network with no cost-share as follows:
- There is no cost for medications Optum Rx’s Preventive drug (ACA) list for all plan participants.
- Additionally, for Optum Rx HSA Plan participants, when you purchase other preventive medications listed on Optum Rx’s 2024 Preventive Drug list, your coverage will be 100% with no deductible or coinsurance applied.
- To see Optum Rx’s lists of preventive medications, visit optumrx.com. For cost details regarding preventive medications and the Optum Rx Premium Formulary, contact Optum Rx at 1-844-368-0693.
Kaiser Permanente Prescription drug benefits (for California residents)
| Plan features | Kaiser HRA | Kaiser HSA | Kaiser HMO |
|---|---|---|---|
| Retail Generic (up to a 30-day supply) |
$10 copay | $10 copay after deductible | $10 copay |
| Retail Brand Formulary (up to a 30-day supply) |
$30 copay | $30 copay after deductible | $30 copay |
| Mail Generic (up to a 100-day supply) |
$20 copay | $20 copay after deductible | $20 copay |
| Mail Brand Formulary (up to a 100-day supply) |
$60 copay | $60 copay after deductible | $60 copay |
| Specialty (up to a 30-day supply) |
20% coinsurance (not to exceed $150) |
20% coinsurance after deductible (not to exceed $250) |
20% coinsurance (not to exceed $250) |
Generics
Generic drugs usually cost less than brand name drugs.
Generic drugs are reviewed by the FDA to ensure that they work the same as the brand-name drug in dosage, safety, quality, performance, strength and usage.
To help keep prescription drug costs in check, prescriptions are automatically filled with a chemically equivalent generic drug, if available and appropriate. If you choose a brand drug when a generic is available, you will pay the difference between the brand medication and the generic, plus the coinsurance. However, if your doctor indicates “Dispense as Written” on your prescription because the brand is medically necessary, you will receive the brand drug and only pay the brand copay.
Note: If you choose a brand drug when a generic is available, you will pay the difference between the brand medication and the generic, plus the coinsurance.
Preferred brand drugs
Brand-name drugs on the Optum Rx preferred list are less expensive than using a non-preferred drug.
Non-preferred brand drugs
Brand-name drugs that are not on your preferred list may cost you more, even if they are recommended by your doctor.
Maintenance medications
Long-term medications, also known as maintenance drugs, are taken on a regular basis (three months or longer) to treat conditions such as high cholesterol, high blood pressure and asthma.
Specialty drugs
A specialty drug is a medication used to treat chronic, complex conditions like multiple sclerosis, hepatitis C and cancer. Specialty medications can include oral solids, or can be injected, infused or inhaled and may require special handling, such as refrigeration.
Preventive medications
Certain preventive medications and supplies are covered at no cost to you and are not subject to meeting a deductible. These medications require a prescription and are subject to certain eligibility requirements. Check with your medical plan provider for details.