Things to know about ​your Drug Benefit

If you have drug coverage as part of your health plan, you may see these kinds of charges –



The amount you must pay for covered health care and drugs before your health plan begins to pay. Your drug coverage may have a deductible that includes both drug and medical services costs. Or, your deductible may only count your drug costs.

Once you have met your deductible (if you have one), your drug coverage provides benefits for covered drugs for the rest of the coverage period. Your share of the cost for each claim may include a copay or coinsurance. ​Your plan pays the rest of the cost of the drug.


Copayments (or Copays)

A fixed amount you pay based on the category or tier your medicine is in. You can find this information on our Drug Formulary.​


Below is an example ofbenefits –

  Copay Tier  Example Copay
Preferred ​Generics
1 $10
Preferred Brands
2 $35
Non-​Preferred (generics or brands) 3 $60
Specialty Medications 4 $100
Outcomes Benefit
(drugs noted with ​RXO on the Formulary)
Outcomes $5

Examples of common benefits are described. Your employer may have purchased a plan that is a modification of the listed descriptions.



The amount you pay for a medication or service.  It is usually a percentage of the cost of the medication. For example, if your plan pays $100 for a drug, a coinsurance payment of 20% would be $20.   Since the prices of drugs can change, your cost share for that drug may also change from time to time. ​


Out-of-Pocket Limit

Your benefit may or may not include an out-of-pocket limit.  An out-of-pocket limit is the most you or your family will pay during a coverage period for covered charges. This is usually 12 months. This benefit may include medical and dental services and drugs (pharmacy), or it may just be your drug costs. ​

Within a family, there may be two types of out-of-pocket limits: individual and total family. Each individual in a family may have out-of-pocket limits. Once a family member has met the individual limit, that family member pays no out-of-pocket costs for the rest of the coverage period.  There may also be family out-of-pocket limits. Once the entire family has met the family out-of-pocket limit, no one in the family will pay out-of-pocket costs for the rest of the coverage period. ​