Covered California Silver 94 Rx Benefits

One of the most popular Health Plans, the Covered California Silver 94 plan includes minimal copays for Rx benefits and no Rx deductible. That means that from the beginning, the only cost associated with Tier 1, 2, and 3 drugs is the copay. Tier 4 drugs, however, are subject to a very reasonable coinsurance of 10% of the cost of the drug up to a maximum of $150 per script.

If you take multiple medications, expensive medications or you experience a year in which you need a lot of prescriptions, the most you will pay for anything in a year (prescription drug costs included) is the out-of-pocket maximum which is $1,150 for an individual or $2,300 for a family.

Coverage is generally calculated per script or each time the prescription is filled for up to (but not exceeding) a 30 day supply of the drug. For a 1-30 day supply the “per script” cost would have to be met once. For a 31-60 day supply the “per script” cost would have to be met twice. For 61-90, three times. Etc.

In the case of the Silver 94 plan, only Tier 4 (specialty) drugs are subject to the “per script” rule.

Example 1:

You’re prescribed a Tier 1(generic) drug by your Doctor that costs $100. You will only pay the $3 copay.

Example 2:

You’re prescribed a Tier 2 (preferred brand) drug by your Doctor that costs $200. You will only pay the $10 copay.

Example 3:

You’re prescribed a Tier 3 (non-preferred brand) drug by your Doctor that costs $400. You will only pay the $15 copay.

Example 4:

You’re prescribed a Tier 4 (specialty) drug that costs $5,000. You will pay 10% of the cost of the drug up to a maximum of $150. So, the total you will have to pay for the $5,000 Rx is $150.