Pharmacy
Employees with health insurance through PEHP have a pharmacy benefit. Prescriptions can be filled at most pharmacies nationwide. The pharmacy benefit also includes a home delivery service through Express Scripts.
| Prescription Drugs | In-Network Provider | Out-Network Provider (Balance billing may apply) |
|---|---|---|
| 30-Day Pharmacy (Retail Only) |
Tier 1: 10% of discounted cost, $7 minimum / No maximum Tier 2: 25% of discounted cost, $40 minimum / No maximum Tier 3: 50% of discounted cost, $70 minimum / No maximum |
Plan pays up to the discounted cost, minus the preferred co-pay (if applicable). You pay any balance. |
| 90-Day Pharmacy (Maintenance Only) |
Tier 1: 10% of discounted cost, $17 minimum / No maximum Tier 2: 25% of discounted cost, $100 minimum / No maximum Tier 3: 50% of discounted cost, $175 minimum / $200 maximum |
Not Covered |
| Specialty Medications, Retail Pharmacy Up to 30-day supply |
Tier A: 20%, No maximum co-pay Tier B: 30%, No maximum co-pay |
Plan pays up to the discounted cost, minus the preferred co-pay (if applicable). You pay any balance. |
| Specialty Medications, Office/Outpatient Up to 30-day supply |
Tier A: 20%, No maximum co-pay Tier B: 30%, No maximum co-pay |
Tier A: 40%, No maximum co-pay Tier B: 50%, No maximum co-pay |
| Specialty Medications, through Home Health or Accredo Up to 30-day supply |
Tier A: 20%, $150 maximum co-pay Tier B: 30%, $225 maximum co-pay Tier C1: 10%, No maximum co-pay Tier C2: 20%, No maximum co-pay Tier C3: 20%, No maximum co-pay |
Not Covered |
Notes:
- In- and Out-of-Network deductibles and Out-of-Pocket Maximums are combined and accumulate together.
- Out-of-Network Providers may charge more than the In-Network Rate unless they agree not to.
- Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or Out-of-Pocket Maximum.
- You pay 20% of the In-Network Rate after the Out-of-Pocket Maximum is met for Out-of-Network Providers.