Prescription Drug Coverage Options

Understanding how carriers cover outpatient prescription drugs can be confusing and will be much  different coverage if you are used to employer benefits.

Carriers all have different prescription benefits, with one common element; the network of providers (pharmacies).  All plans are a Preferred Provider Organization (PPO), providing you access (no referral required) to pharmacies that are contracted with your insurance carrier.  What does it mean for a pharmacy to have a contract with your insurance carrier???  Well, it means that your pharmacy has a set fee that they can bill a carriers member for prescriptions, known as the "contracted rate", which can range between 2-70% below retail cost for someone without insurance.  The final amount owed, known as the "allowable amount" is what the member is responsible to pay .  Every pharmacy will have a different "allowable amount"


If you currently take prescription medication other than contraceptives, carriers such as Blue Cross and Blue Shield of Illinois (BCBSIL), Celtic and Aetna, will not cover for the first 12 months.  These 3 carriers have a 12 month waiting period for pre-existing medical conditions, and BCBSIL only waives if current coverage is BCBS without a break in coverage greater than 63 days, and Aetna will waive no matter the carrier as long as there is not a break in coverage greater than 63 days.  All other carriers will increase premiums to cover medications or exclude coverage on medications as the cost more than the premium being collected.


Blue Cross and Blue Shield of Illinois (BCBSIL) offers 2 options, with the 1st option requiring a $500 deductible or lower on a specific plan design. With this option, the member pays a $10 copay for generics and cost shares on the "allowable amount" on Preferred and Brand Name prescription drugs...to not spend more than $100 on each prescription fill.  The amount that the member pays does not apply to the plan.  The 2nd option, which is available on all deductibles above $500 has the member paying the "allowable amount" toward the plan deductible.

All other carriers when not choosing a HSA plan design provide the member with a immediate $10 or $15 copay for generic drugs (level 1), to then have the member pay the "allowable amount" on Preferred (level 2) and Brand Name (level 3) drugs towards a separate $500 deductible before receiving a specific copay amount per drug level...none of which applies to the plan deductible.  Depending on the carrier, prescription drug deductibles can increase upwards to $1,000 or you can pay additional premium to lower down to $150 or $200.

To be honest...if you currently are taking prescription medications, it would be best to pay the "allowable amount" and chip away at the plan deductible...lowering your overall calendar year financial exposure to covered expenses.

For further information on benefits, please contact the shoppe.

-The Shoppe