LAPRA 2018/19 Benefits Guide for Active Members

7 When You Need a Prescription When you enroll in a LAPRA medical plan, you automatically receive prescription drug coverage as shown in the table below. Note that prescription drug co-pays count towards your medical plan calendar year out- of-pocket maximum in the Anthem Blue Cross CaliforniaCare Plus HMO and the Kaiser HMO, but there is a separate prescription drug out-of-pocket maximum for the Anthem Blue Cross Prudent Buyer PPO. To save money on prescription drugs, request that your doctor write your prescriptions for “generic” drugs whenever possible. Generic drugs are often the therapeutic equivalent of their brand-name counterparts, but cost significantly less. Under the Anthem Blue Cross PPO and HMO plans, if a generic drug is available and a brand-name drug is dispensed because your physician specifies “dispense as written,” you will pay the applicable co-pay for the brand name drug you receive. See footnote #2 below if your physician does not specify “dispense as written.” You can purchase up to a 90-day supply of most maintenance drugs at a retail pharmacy under the Anthem Blue Cross Prudent Buyer PPO and CaliforniaCare Plus HMO. Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. Prescription Drugs Anthem Blue Cross Prudent Buyer PPO Anthem Blue Cross CaliforniaCare Plus HMO (California Residents Only) Kaiser HMO (California Residents Only) Calendar Year Prescription Drug Out-of-Pocket Maximum $4,850 per person $7,700 per family (not to exceed $4,850 for any one person) N/A N/A Retail Pharmacy • Generic 1 • Brand 2 • Non-formulary • Maintenance Drugs 3 • Specialty Drugs 4 • Retail Supply $15 co-pay $25 co-pay $40 co-pay 2 co-pays (90-day supply) 20% co-pay, 1 max $150/prescription Up to 30 days (90 days for maintenance drugs 3 ) $15 co-pay $25 co-pay $40 co-pay 2 co-pays (90-day supply) 20% co-pay, 1 max $150/prescription Up to 30 days (90 days for maintenance drugs 3 ) $15 co-pay $30 co-pay $30 co-pay n/a Up to 30 days Mail Order • Generic 1 • Brand • Non-formulary • Specialty Drugs 4 • Mail Order Supply 1-30 day supply / 31-90 day supply $15 co-pay / $30 co-pay $25 co-pay / $50 co-pay $40 co-pay / $80 co-pay 20% co-pay, max 20% co-pay, max $150/prescription $300/prescription Up to 90 days 1-30 day supply / 31-90 day supply $15 co-pay / $30 co-pay $25 co-pay / $50 co-pay $40 co-pay / $80 co-pay 20% co-pay, max 20% co-pay, max $150/prescription $300/prescription Up to 90 days 1-30 day supply / 31-100 day supply $15 co-pay / $30 co-pay $30 co-pay / $60 co-pay $30 co-pay / $60 co-pay n/a Up to 100 days 1 $0 co-pay for women’s prescription contraceptives. 2 Under the Anthem Blue Cross PPO and HMO plans, you will have to pay the co-pay for the generic drug plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug, but not more than 50% of the average cost for the tier that the brand name drug is in. 3 Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. To determine if your medication qualifies as a maintenance drug, contact Anthem Blue Cross at 855-250-8954. Maintenance drugs do not include any controlled substances, smoking cessation or weight management medications. 4 20% co-pay does not apply to insulin. Regular co-pays apply.