Wisconsin Prescription Drugs

When you enroll in a HSHS Healthy Plan medical option, you will automatically have prescription drug coverage. If you take any medications regularly, prescription drug costs can add up to a significant part of your overall health care expenses. Knowing how your medical plan’s prescription drug coverage works and what to do to manage costs can help you make good buying decisions and lower your out-of-pocket costs.

The program features coverage for both prescriptions you fill at your participating local retail pharmacy – and a mail service option through WellDyneRx designed to help you save time and money on maintenance medications. After you meet the separate prescription drug deductible for your medical plan option, the plan pays 80% of the cost of covered preferred generic prescriptions and 70% of the cost of covered preferred brand-name medications. When you reach the prescription drug out-of-pocket maximum for your medical plan option, the plan pays the full cost of your prescriptions for the rest of the calendar year, with the exception of the ancillary fee that applies when you receive a brand-name drug for which a direct generic equivalent exists.

Prescription drug benefits feature a formulary. Your cost for brand-name and generic drugs will be lower when you use a preferred (formulary) medication. Preferred (formulary) medications are noted with an “FB” (brand name) or an “FG” (generic) on the formulary listing. For non-preferred brand-name drugs, you will pay an additional $15 per prescription for prescriptions filled at a retail pharmacy and an additional $45 for prescriptions filled through mail service. Non-preferred medications are noted with an “NP” on the formulary listing. The formulary is compiled by an independent group of doctors and pharmacists. Medications are reviewed and approved for the formulary based on medical effectiveness and cost, which helps keep costs affordable for you and the HSHS Healthy Plan. Please note that medications on the formulary with the notation “NC” are not covered.

For more information including retail pharmacy, mail service, generic and brand name drugs, prior authorization and step therapy, please view the Flex Plan Decision Guide.

The prescription drug benefit does not coordinate with other prescription drug plans, and covers only prescriptions filled at pharmacies participating in the Navitus network.