Covered California Silver 87 Rx Benefits
One of the most popular Health Plans, the Covered California Silver 87 plan includes a $25 individual Rx deductible ($50 for families) and minimal copays per script after the Rx deductible is met.
|Individual||$25 Rx deductible|
|Family||$50 Rx deductible|
|Tier 1 (generic) Rx Copay||$5 prescription (retail) / $10 prescription (mail order). After drug deductible.|
|Tier 2 (preferred brand) Rx Copay||$25 prescription (retail) / $50 prescription (mail order). After drug deductible.|
|Tier 3 (non-preferred brand) Rx Copay||$25 prescription (retail) / $50 prescription (mail order). After drug deductible.|
|Tier 4 (specialty) Rx Copay||15% coinsurance up to $150 prescription. After drug deductible.|
The Rx deductible works similarly to any deductible. In order for your coverage to kick in, you must first pay for services up to the amount of the deductible. Once the deductible is met, your health plan benefits will kick in and you will only have to cover the cost of the copay for your Rx. However, it’s important to remember that paying into you Rx deductible does not count toward your plans medical deductible and vice versa. They are always separate.
If you take multiple medications, expensive medications or you experience a year in which you need a lot of prescriptions the most you will pay for anything in a year (prescription drug costs included) is the out-of-pocket maximum which is $3,000 for an individual and 6,000 for families.
Coverage is generally calculated per script or each time the prescription is filled for up to (but not exceeding) a 30 day supply of the drug. For a 1-30 day supply the “per script” cost would have to be met once. For a 31-60 day supply the “per script” cost would have to be met twice. For 61-90, three times. Etc.
In the case of the Silver 87 plan, only Tier 4 (specialty) drugs are subject to the “per script” rule.
You’re prescribed a Tier 1(generic) drug by your Doctor that costs $100. You will pay the $5 copay and $25 since Tier 1 (generic) drugs are subject to the Rx deductible.
You’re prescribed a Tier 2 (preferred brand) drug that costs $500. You will pay $25 to cover the Rx deductible and the $25 copay. Your total cost is $50.
You’re prescribed a Tier 4 (specialty) drug that costs $5,000. You will pay $25 to cover the Rx deductible and 15% of the remaining cost up to a maximum of $150. So, the total you will have to pay for the $5,000 Rx is $175.
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