Covered California Minimum Coverage Plan Rx Benefits
One of the lowest cost health plans, the Minimum Coverage plan is designed to cover you for catastrophic events. So that means prescriptions are not covered well on this type of plan. Prescriptions are only covered after you meet the out-of-pocket maximum (OOP Max).
| You pay… | |
| Individual | $10,600 OOP Max, per individual, for medical and drugs |
| Family | $21,200 OOP Max, per family, for medical and drugs |
| Tier 1 ( most generics) Rx Copay | 100% until maximum OOP Max is met |
| Tier 2 (preferred brand) Rx Copay | 100% until maximum OOP Max is met |
| Tier 3 (non-preferred brand) Rx Copay | 100% until maximum OOP Max is met |
| Tier 4 (specialty) Rx Copay | 100% until maximum OOP Max is met |
No Rx Deductible
The Covered California Minimum Coverage plan does not include a separate drug deductible, but the member will need to pay the OOP Max before coverage kicks in. The OOP Max applies to all Rx regardless of tier.
Rx Maximum
It is good to know that there is a cap if you experience an expensive year. If you take expensive medications or you experience a year in which you need a lot of prescriptions the most you will pay for anything (prescription drug costs included) in a year, is the OOP Max (see chart above). Generally, once it is met then prescriptions will be covered at 100%.
Example 1
You’re prescribed a Tier 1(generic) drug by your Doctor that costs $100. You will pay the full $100 since the drug cost is less than the OOP Max.
Example 2:
You’re prescribed a Tier 4 (specialty) drug that costs $10,000. You will pay the full $10,000 since the drug cost is less than the out-of-pocket maximum.
Later that year you’re prescribed another Tier 4 (specialty) drug by your Doctor. The cost of this drug is also $10,000. This time you will only pay $600 (the remaining balance of your OOP Max).
Tip: Consult your insurance carrier and doctor before filling a prescription to understand costs and required authorization procedures and to see if there are options for less expensive medications.
Later that that year you’re prescribed another Tier 4 (specialty) drug by your Doctor. The cost of this drug is also $5,000. This time you will only pay $4,450 (the remaining balance of your out-of-pocket max) since you had previously paid $5,000 toward your maximum out-of-pocket.