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  4. State Employee Benefits

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 or the Quality Care Health Plan have specific policies, as well as maintenance and nonmaintenance prescription networks they should be aware of prior to selecting a pharmacy.

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.

 

Below are the copayments for FY2016 through FY2018
​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​

 

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.

 

 

Updated 05/12/2017