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Prescription Coverage
Health plan participants (members and dependents) are required to pay a prescription deductible each plan year.
Plan participants enrolled in any of the State health plans have prescription drug coverage included in their health plan benefits. Prescription benefits are administered by the health plan's prescription benefit manager (PBM). Members who use the PBMs pharmacy network to obtain their medication will be charged the applicable prescription copayment after the prescription deductible has been met. A pharmacy that is not in the network may charge more than the copayment amount; therefore, members should verify that a pharmacy is in-network to avoid high prescription costs.
Plan participants enrolled in HealthLink OAP, Aetna OAP, Blue Cross Blue Shield OAP, the Consumer Driven Health Plan (CDHP), or the Quality Care Health Plan (QCHP) have specific policies, as well as maintenance and non-maintenance prescription networks, they should be aware of prior to selecting a pharmacy.
Maintenance Choice: The Maintenance Choice tier is available to those members covered under an OAP, QCHP, or CDHP. This tier allows members to obtain specific medications in a 90-day supply from a CVS Caremark® pharmacy or through the CVS Caremark® Mail Service Pharmacy for half of the copayment. Please contact CVS Caremark® to determine if your medication is available under this benefit.
Reduced Tier 1: The Reduced Tier 1 pharmacy benefit is available through an HMO carrier. This tier allows members to obtain specific medications in either a 30-day or 90-day supply for a reduction of the normal tier 1 applicable copayment. Please contact your HMO to determine if your medication is available under this benefit.
Plan participants enrolled in BlueAdvantage HMO, Health Alliance HMO, Aetna HMO, and HMO Illinois may also receive a discount when they fill a 90-day supply of medication. Plan participants enrolled in one of these plans should contact their health plan for information regarding discounts and formulary lists. When enrolled in an HMO plan, a 90-day supply of medication is 2.5 times the copayment amount when ordered through the plan's mail order pharmacy. Some HMO plans also offer the 2.5 copayment discount for a 90-day supply filled at a retail pharmacy. Check with your HMO to determine if your plan offers a 90-day supply through a retail pharmacy.
Under the Affordable Care Act, Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs, will be covered by the plan without cost-sharing requirements.
FY25 State Prescription Copayments
(Effective July 1, 2024)
| *Reduced Tier I |
Tier I |
Tier II |
Tier III |
||
| HMOs |
Prescription Drug Deductible $150 per HMO enrollee. |
||||
| 30-day supply |
$4.00 |
$20.00 |
$35.00 |
$60.00 |
|
| 90-day supply |
$10.00 |
$50.00 |
$87.50 |
$150.00 |
|
| |
|||||
| OAPs |
Prescription Drug Deductible $150 per OAP enrollee. | ||||
| 30-day supply |
|
$20.00 |
$35.00 |
$60.00 |
|
| 90-day supply |
| $50.00 |
$87.50 |
$150.00 |
|
| **90-day Maintenance Choice |
| $25.00 |
$43.75 |
$75.00 |
|
| |
|||||
| QCHP |
Prescription Drug Deductible $175 per QCHP enrollee. | ||||
| 30-day supply |
|
$20.00 |
$40.00 |
$65.00 |
|
| 90-day supply |
| $50.00 |
$100.00 |
$162.50 |
|
| **90-day Maintenance Choice
|
|
$25.00 |
$50.00 |
$81.25 |
|
| |
|||||
| CDHP |
30 -day supply |
| 90% - Deductible Applies |
90% - Deductible Applies |
90% - Deductible Applies |
| 90-day supply |
| 90% - Deductible Applies |
90% - Deductible Applies |
90% - Deductible Applies |
|
| **90-day Maintenance Choice
|
| 95% - Deductible Applies |
95% - Deductible Applies |
95% - Deductible Applies |
|
* Applies to specific medications as defined by plan.
**Medications received at CVS Caremark® Pharmacy or through CVS Caremark® Mail Service Pharmacy
Prescription Deductible
Note: If the cost of the drug is less than the plan's copayment, the plan participant will pay the entire cost of the drug, all of which will be applied toward the deductible.
Coverage for specific drugs may vary depending upon the health plan. It is important to note that formulary lists are subject to change any time during the plan year. To compare formulary lists (preferred drug lists), cost-savings programs and to obtain a list of pharmacies that participate in the various health plan networks, plan participants should visit the website of each health plan. Certain health plans notify plan participants by mail when a prescribed medication they are currently taking is reclassified into a different formulary list category. Plan participants should consult with their physician to determine if a change in prescription is appropriate.
Prescription Vacation Override Process (For the Self-Insured Plans only)
State of Illinois (SOI) employees and their covered dependents who are actively enrolled in the SOI’s OAP, QCHP, or CDHP health plans are eligible for 2 Prescription Vacation Overrides per year.
Employees and/or their covered dependents going on vacation or an extended stay outside of the United States, who require an early refill or who will need medications to cover a period greater than the current prescription refill, must request an exception for a Prescription Vacation Override for that time period. This form Prescription Vacation Override Request needs to be filled out in its entirety and sent to the email/physical address at the bottom of the form.
Note: If you are enrolled in a State of IL – HMO health plan you will need to contact your health insurance carrier to obtain information on their process for this type of request.
MAPD MEMBERS – Need to contact Aetna directly to obtain their process for this type of request.