Your medical plan helps keep prescription drug costs in check. What you pay depends on the type of medication and how you choose to fill your prescription — whether at a CVS Caremark retail pharmacy or through mail order. Think of it as having options — and the flexibility to choose what works best for you.
What you pay for in-network prescriptions
If you’re enrolled in a Blue Cross and Blue Shield of Illinois medical plan, your prescription drug benefits are administered by CVS Caremark. You can get a 30-day supply of medication from retail pharmacies and a 90-day supply through mail order.
Note about deductibles and out-of-pocket maximums: The QHDHP and the PPO plan treat these costs differently. Prescription drug costs apply to the QHDHP annual deductible ($3,400 individual or $6,000 family) but they do not apply to the PPO plan annual deductible.
Prescription drugs are also included in the out-of-pocket maximum for the QHDHP ($6,000 individual or $12,000 family), but the PPO plan has a separate out-of-pocket maximum for prescriptions ($2,000 individual or $4,000 family).
30-day retail supply
30-day retail supply
| Drug tier | PPO Plan (with HRA) | QHDHP (with HSA) |
|---|---|---|
| Tier 1: Generic | You pay 20%; $10 min. / $25 max. | You pay 20% after deductible |
| Tier 2: Preferred brand | You pay 30%; $15 min. / $150 max. | You pay 20% after deductible |
| Tier 3: Non-preferred brand | You pay 50%; $15 min. / $200 max. | You pay 20% after deductible |
90-day mail-order and maintenance supply
90-day mail-order and maintenance supply
| Drug tier | PPO Plan (with HRA) | QHDHP (with HSA) |
|---|---|---|
| Tier 1: Generic | You pay 20%; $20 min. / $50 max. | You pay 20% after deductible |
| Tier 2: Preferred brand | You pay 30%; $30 min. / $300 max. | You pay 20% after deductible |
| Tier 3: Non-preferred brand | You pay 50%; $30 min. / $400 max. | You pay 20% after deductible |
Specialty medications
Specialty medications
When you’re enrolled in PrudentRx, you may pay nothing for eligible specialty drugs. Specialty drugs are high-cost medications used to treat complex chronic conditions. You are automatically enrolled in PrudentRx once a specialty drug is prescribed to you, unless you opt out. If you opt out of PrudentRx, you’ll pay 30% coinsurance for fills. If you’re enrolled in the QHDHP, you’ll need to meet the IRS minimum deductible before the $0 cost share applies.
How to save on prescriptions
A few simple choices can help you get the most out of your prescription benefits and keep more money in your pocket.
Start with these smart saving tips:
- Check the formulary first. The formulary is the list of medications that may be covered by your plan. If your medication isn’t on the list, it typically costs more. To find covered medications, visit the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
- Know your drug tier. Medications are grouped into tiers, and your cost depends on which tier your prescription falls into. In general, lower tiers mean lower costs. You can check tiers and pricing on the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
- Choose generics when possible. Generic medications usually cost less and work the same as brand-name drugs. Choosing a brand-name drug when a generic is available may mean paying a higher copay or coinsurance plus the cost difference between the two drugs.
- Preventive medications may be free. Under the Affordable Care Act, certain preventive medications are covered at 100% when filled in-network. See the list on the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
Prior authorization may be required
Some medical services and prescription drugs require prior authorization before they are covered. This means your health care provider must get approval from your insurance provider in advance. If prior authorization isn’t obtained, you may be responsible for the full cost. This process helps ensure that care is safe, appropriate, and covered under the plan. Review the plan documents on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in) for more information. On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.