Prescription Drug Coverage

You are automatically enrolled in Prescription Drug Coverage when you enroll in a BCBSIL medical plan.

BCBSIL and its pharmacy partner, Prime Therapeutics, maintain a list of outpatient prescription drugs that are eligible for coverage under the plan.  The list of covered drugs is called the Performance Drug List, and you can access this information through the BCBSIL website:

1. Log in to bcbsil.com/ajg and go to “Learn more about your prescription drug benefits.”
2. Select “Performance Drug List.”
3. Search for the drug and dose your doctor has prescribed for you.

The plan also provides coverage for a category of outpatient medications called Specialty Drugs*. A list of Specialty drugs covered under plan is available through BCBSIL and its Specialty drug partner, Accredo.

If a drug is not on the Performance Drug List or the Accredo specialty drug list, it is not covered under the Gallagher medical plan.

*Specialty drugs administered on an inpatient basis are processed and paid as a medical claim, not a prescription drug claim.

You can fill your prescriptions at any pharmacy that participates in the plan’s pharmacy networks. The networks include many major pharmacy chains* and independent pharmacies, as well a mail-order service option that offers the convenience of home delivery. The pharmacy network you will use depends on the type of prescription you are filling:

*Prescriptions obtained through pharmacies outside of the network are not eligible for Rx benefits under the plan.

Deductible: In the PPO+HSA1 and PPO+HSA2 plans, prescription drugs are subject to the medical plan deductible.  You pay the full cost of your prescriptions until your medical plan deductible is satisfied; prescription drug benefits begin once your annual deductible has been met for the year.

In the PPO+HCA plan, prescription drugs are exempt from the medical plan deductible; prescription drug benefits are applied to your claims whether you have satisfied your medical plan deductible for the year or not.

Coinsurance: Under the plan’s prescription drug benefit, your cost for a prescription depends on the type of drug you are obtaining, the quantity requested, and where you buy it:

*If you request a brand-name drug when a generic in the same drug category is available (a generic equivalent), it will cost you more. You’ll pay the difference between the generic and the brand drug, even if your doctor requests “dispense as written.” Plus, you’ll pay the higher coinsurance level that applies to brand-name prescriptions.

**Outpatient specialty drug orders that are not fulfilled through Accredo are excluded from coverage and are not eligible for plan benefits.

Certain drugs are subject to advance review protocols that ensure safe handling and proper utilization and help manage costs for you and the plan.  Your prescription may by subject to prior authorization, step therapy or quantity limits or may be excluded from coverage.