What you pay for drugs
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How much you pay depends on the tier your prescription drug is in. The prescription drug deductible applies to Tier 2 and Tier 3 drugs, as indicated in the table below.
You can get up to a 90-day supply for most drugs—except for specialty drugs, which are usually limited to a maximum 30-day supply.
|Tier||All network pharmacies
Retail and mail-order
|The most you'll pay
Network pharmacies only
|Value Tier||5% coinsurance
|$10—Up to a 30-day supply
$20—31-60 days’ supply
$30—61-90 days’ supply
Select generic drugs
|$25—Up to a 30-day supply
$50—31-60 days’ supply
$75—61-90 days’ supply
|$75—Up to a 30-day supply
$150—31-60 days’ supply
$225—61-90 days’ supply
|Specialty drugs* only—$150
No cost-limit for non-specialty drugs
*Specialty drugs must be purchased through the plan's network specialty pharmacy, Ardon Health.
TIP: Value Tier or Tier 1 drugs do not count toward your prescription drug deductible. If you get only Value Tier and Tier 1 drugs, you won’t need to pay the deductible.
Your annual prescription drug deductible is $100 per person (maximum of $300 for a family of three or more). You pay the deductible and your coinsurance to the pharmacy for Tier 2 and Tier 3 (brand-name) drugs. For drugs that cost less than $100, you pay the cost of the drug until you meet the $100 deductible in full.
The deductible applies regardless of where you purchase your prescription. Once you meet the prescription drug deductible, the plan pays benefits for the rest of the calendar year.
This limit controls how much each enrolled person pays for covered prescription drugs and products during a plan calendar year. It does not limit how much the plan pays.
The prescription drug out-of-pocket limit is $2,000 per person. There is no family maximum. Each member must meet their own prescription drug out-of-pocket limit separately.
Your prescription drug coinsurance up to the prescription cost-limit (see chart above), when it applies, and your prescription drug deductible both count toward this limit.
The following do not count toward this limit:
- Amounts paid by the plan, including services covered in full (preventive).
- Amounts exceeding the allowed amount for drugs paid to non-network pharmacies. (This is called balance billing.)
- Drugs and products not covered by the plan. See Guidelines for Drugs Not Covered.
- Costs for medical services, including drugs covered under the medical benefit. (See how the medical out-of-pocket limit works.)
- Costs paid for other enrolled family members’ prescription drugs and products.
You will still be responsible for paying numbers 2-5 above after you meet your individual prescription drug out-of-pocket limit.
After you reach this limit, the plan pays 100 percent of the allowed amount for covered drugs and products. If you receive drugs from a non-network pharmacy that charges more than the allowed amount, you must still pay the difference (balance billing).
Washington State Rx Services
Business hours: Monday-Friday 7:30 a.m. to 5:30 p.m. Pacific Time