Prescription coverage will differ a great deal depending on type of coverage you have in place. For purposes of this discussion, we are only describing the coverage under a an individual or family Texas health insurance policy.
If you have a Health Savings Account (HSA policy), then your plan can cover prescriptions in several ways. The deductible on an HSA is generally for both medical and prescription expenses. Since most all HSA plans are also PPO plans, you will receive the PPO contracted rate on all prescriptions (this will generally give you about 30-50% off on generic medications and 10-40% off on brand name medications) and whatever you spend on the medication will count toward the deductible of your Health Savings Account plan. Once you hit that deductible (remember that it’s a combination medical/prescription deductible) on your HSA, the medications will either be covered at 100% or covered by a co pay applicable to whether it’s a generic drug or a brand name drug.
For example, on the BCBS of Texas HSA Plan VIII for individuals, this plan covers all prescriptions at 100% after the $5,000 deductible has been satisfied. However, on the BCBS of Texas HSA plan VI for families, once you hit the 5,000 deductible, you’ll have a $10 co pay for generic drugs, a $50 co pay for brand name formulary drugs and a $65 co pay for brand name non-formulary drugs.
If you have a more traditional PPO policy (one that is not HSA eligible), you will generally have prescription coverage that is separate and distinct from your medical coverage. On most Texas health insurance plans, you’ll see three styles of prescription coverage as follows:
1) A co pay on all prescriptions without having to satisfy an RX deductible first. For example, on the BCBS of Texas Select Blue Advantage plan, you have $10/$30/$45 co pays for generic drugs, brand name formulary and brand name non-formulary drugs respectively.
2) A co pay on your prescriptions only after a small deductible has been satisfied first. For example, on the BCBS of Texas Select Choice plans, you must first satisfy a $200 deductible first and then it’s $10/$30/$45 (again for generic/brand name formulary/brand name non-formulary respectively) or
3) some plans have a co pay for generic prescriptions from the very first day without having to satisfy a deductible first. However, on the brand name drugs, you’ll have a small deductible (typically $250-$500) first before the co pays begin. For example, on the Texas CIGNA Open Access 2000 policy, you have a $10 co pay on generic medications with no deductible, but on the brand name medications, you must satisfy a $250 deductible first and it’s a $35 co pay for brand name formulary and a 60 co pay for brand name non-formulary.
Feel free to call us at 866.270.6209 if you have questions on your policy or visit us at http://www.selectedbenefits.com