New out-of-pocket maximum to help with high drug costs
Members in the PEBB Statewide and Providence Choice plans will have an out-of-pocket maximum for prescription drugs next year.
Your share of costs for covered prescriptions in these plans will be limited to $1,000 per person after you meet your prescription deductible. The family maximum will be $3,000 ($1,000 per person times three family members).
This is good news if you or a family member is taking many brand-name medications at the $30 co-pay tier – or even one specialty drug, which have a $100 co-pay.
Specialty drugs are typically high-cost injectable, infused, oral or inhaled drugs that require close supervision and monitoring.
Even if you don’t take a specialty drug, you can still see costs add up when you use brand-name drugs on the formulary. Ask your provider if there are alternatives that would work as well for you at lower cost.
Keep in mind that Value drugs in the PEBB Statewide and Providence Choice formulary have no co-pay. They include most generic and some brand drugs that are typically used to treat the most common chronic conditions in the population. Click here for more on Value drugs.
Clearing up confusion on coverage of non-formulary drugs
There has been some confusion about the process for determining coverage exceptions for non-formulary drugs in the PEBB Statewide plan.
Non-formulary drugs are prescription medications that are not on the plan’s list of covered drugs.
Click here for a fact sheet that clarifies the process for seeking coverage of non-formulary drugs in PEBB Statewide.
Click here to see the formulary in the PEBB Statewide and Providence Choice Plans.
Click here to see the formulary in Kaiser Permanente plans.