This plan has a tiered prescription benefit. This means for each prescription you will pay co-insurance, which will vary depending on the tier (or category) of the drug.
The co-insurance amounts are:
- Tier 1: 0% - Generic drugs are provided at no cost to the insured
- Tier 2: 30% - Wellmark name brand formulary drugs
- Tier 3: 50% - Wellmark non-formulary drugs
You can search the Wellmark drug list to determine which tier specific medications are in. Our plan is BlueRX Complete.
Drugs available as over-the-counter medicines without a prescription are not covered under this plan.
Participating pharmacies are responsible for submitting your prescription claims electronically.
The OPM expense provision for prescription drugs is separate from the medical OPM. The insured is responsible for paying co-insurance on prescriptions (as described above) up to $1,100 for individuals or $2,200 for family in prescription drug cost. Once the OPM has been met, the plan pays 100% of covered expenses incurred during the rest of the calendar year for drugs.
If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-insurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic. This can result in you paying substantially higher costs than if you had chosen the generic drug.
If your physician feels it is important for you to have the brand name drug, they can write the prescription for the brand name drug with the direction “Dispense as written” on the prescription. In this situation, you will not be responsible for the difference between the billed charge for the brand name drug and the billed charge for the generic drug.
Certain drugs are limited per month, benefit period, or lifetime by drug-specific quantity limitations, or by step therapy requirements or prior authorization. The limitations are determined by Wellmark based on medical necessity. For a list of drugs subject to limitations, visit the Wellmark website or check with your pharmacist or physician.