Prescription drugs

Find out how prescription drug coverage works based on the medical plan you elect.

What you need to know

The prescription drug coverage for all Highmark plans is administered by Express Scripts. The Kaiser Permanente and HMSA plans administer their own prescription programs.

What you pay for prescription drugs depends on which medical plan you elect, the type of medication, and where you fill your prescription.

How it works

Your prescription coverage differs in how much you pay when you fill prescriptions. Eligible preventive drugs are always covered by the plans. GLP-1 medications are only covered for diabetes.

Click through the tabs below for more information.

  1. You pay the entire cost.
    You’ll benefit from negotiated rates but will pay the entire cost of your prescription until you meet your deductible.
    PRO TIP: Using pre-tax dollars to pay for your out-of-pocket prescription costs will help you save.
  2. You share the cost with the plan.
    Once you meet your deductible, you’ll pay the coinsurance until you reach the out-of-pocket maximum for your plan.
  3. The plan pays the entire cost.
    Once you meet your out-of-pocket maximum, the plan will pay the full cost of your prescriptions for the remainder of the year.
  1. You pay a copay.
    You’ll benefit from negotiated rates and pay a copay until you reach the out-of-pocket maximum for your plan.
  2. The plan pays the entire cost.
    Once you meet your out-of-pocket maximum, the plan will pay the full cost of your prescriptions for the remainder of the year.
There is no deductible associated with the Kaiser HMO plan.

  1. You pay a copay.
    You’ll benefit from negotiated rates and pay a copay until you reach the out-of-pocket maximum for your plan.
  2. The plan pays the entire cost.
    Once you meet your out-of-pocket maximum, the plan will pay the full cost of your prescriptions for the remainder of the year.
There is no prescription drug deductible with the HMSA PPO.

  1. You pay a copay.
    You pay a copay each time you need a refill or a new prescription. The costs will be applied to your prescription drug out-of-pocket (OOP) maximum.
  2. The plan pays the entire cost.
    Once you reach your prescription drug OOP maximum, the plan will pay 100 percent of the cost of any additional prescriptions you need for the rest of the year.

Get to know Express Scripts

If you’re enrolled in any Highmark plan your prescription coverage is through Express Scripts. The Get to Know Express Scripts tool helps you understand what’s covered by your plan, compare costs for medications at local pharmacies, and more. For an even better experience once enrolled, we recommend creating an account with Express Scripts.

Get a personalized recommendation

Use Ask Me, an AI-powered colleague experience, can simplify the benefits decision-making process and recommend benefit options that may be the best fit for you and your family.

 

What you pay

Retail prescriptions (30-day supply)

Preventive care
Annual deductible11
Annual out-of-pocket maximum
Your copay or coinsurance for generics
Your copay or coinsurance for preferred brand
Your copay or coinsurance for non-preferred brand
Your copay or coisnurance for Specialty Drugs
Highmark
CDHP 3750
In-network
Preventive care drugs covered at 100%
Combined with medical deductible
Combined with medical out-of-pocket maximum
30%
(after deductible)
30%
(after deductible)
30%
(after deductible)
30%
(after deductible)
Highmark CDHP 2250
CDHP 2250
HPN
In-network
Preventive care drugs covered at 100%
Combined with medical deductible
Combined with medical out-of-pocket maximum
20%
(after deductible)
20%
(after deductible)
20%
(after deductible)
20%
(after deductible)
Highmark PPO 1000
PPO 1000
HPN
In-network
Preventive care drugs covered at 100%
Deductible does not apply
Combined with medical out-of-pocket maximum
$10
(copay)
$50
(copay)
$75
(copay)
$150 copay
Kaiser HMO
In-network only1
Preventive care drugs are covered at 100%
None
Combined with medical out-of-pocket maximum
$10
(copay)
$30
(copay)
$30
(copay)
20% up to $250
(no deductible)
HMSA PPO
In-network
Preventive care drugs are covered at 100%
None
$3,600 individual
$4,200 family
$7
(copay)
$30
(copay)
$30
(copay)
20% mostly preferred formullary
25% mostly non-preferred formullary

1 No deductible for preventive prescriptions filled at a preferred retail pharmacy or by mail order.

Ways to save in the Highmark medical plans

If you’re enrolled in a Highmark medical plan, you may be able to save on prescriptions or medical supplies through the following programs:

You can also contact a Quantum Health Coordinator at (866) 317-6103 to see if you qualify for a discount.

Preventive care benefits

Solving health problems is good. Preventing them is better. Certain preventive drugs will be covered at 100 percent or will not be subject to the deductible.

Additional resources