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Open Enrollment: Understanding your pharmaceutical profile and selecting a health plan

Oct. 24, 2020, 4:18 PM

2021 Benefits Open Enrollment

Prescription drug coverage is included with both health plan options for 2021 benefits, but costs apply differently depending on which plan you choose. You should evaluate your prescriptions costs and determine the price you will pay under each plan.

Choice CDHP prescription costs

The Choice CDHP has a combined deductible, meaning that both your medical and prescription costs will count toward your deductible. This means you pay the full cost of prescriptions (and medical costs) until your deductible is met. Once this deductible is met, your prescriptions will be covered at the applicable co-insurance percentage.

  Vanderbilt Pharmacy Retail Network Pharmacy
Co-insurance 20% 40%
Individual Deductible $1,750 $2,300
Family Deductible $3,500 $4,700

Select PPO prescription costs

Select PPO prescription costs are based on co-pays for generic (maintenance and Level 1) drugs and co-insurance for brand (retail) drugs (levels 2 and 3). Co-insurance means you’ll pay for a percentage of the brand drugs, not a flat dollar amount like a co-pay. There is a calendar year prescription co-insurance and co-pay limit of $2,500 for individuals or $5,000 for families.

Select PPO Prescription
Annual OOP maximum Amount
Individual $2,500
Family $5,000

 

Drug Level Vanderbilt Pharmacy
(up to 30 days)
Retail Network Pharmacy
(up to 30 days)
Vanderbilt Mail Order/Pick Up
(up to 90 days)
Maintenance Generic* $1 co-pay $15 co-pay $10 co-pay
Level 1 $10 co-pay $15 co-pay $30 co-pay
Level 2 30% coinsurance w/$100 max 50% coinsurance w/$150 max 30% coinsurance w/$300 max
Level 3 50% coinsurance w/$150 min 70% coinsurance w/$200 min 50% coinsurance w/$450 min
Specialty 10% coinsurance w/$200 max no coverage no coverage

Scenario 1 (for illustrative purposes only, cost estimates assume using Vanderbilt Pharmacy)

John Doe is taking a monthly, Level 1 maintenance drug that costs $150.  He will be enrolling in individual health coverage for 2021. He is not planning for any major health issues this year but will have his annual checkup.

Under the Choice CDHP, he will pay the full $150 every month until he reaches his combined medical and pharmacy deductible of $1,750. Once he reaches $1,750, he will pay $30 (20% of $150) co-insurance each month for his remaining pharmacy costs until his combined pharmacy and medical costs reach the annual out-of-pocket maximum. At that point the plan will pay all additional pharmacy and/or medical costs for the remainder of the year.

Under the Select PPO, he will pay a $10 co-pay every month. Note: There is an annual prescription-only out-of-pocket maximum of $2,500. Once it is met, meds are covered by the plan at 100%.

Scenario 2 (for illustrative purposes only, cost estimates assume using Vanderbilt Pharmacy)

Jane Sampleton and her family take several prescriptions a month that cost a total of $1,200. She will be enrolling in family health coverage for 2021.

Prescription breakout:

  • Level 2 – $100
  • Level 2 – $100
  • Level 3 – $1,000

Under the Choice CDHP, she will pay $1,200 every month until she (in combination with her other family members) reaches the family deductible of $3,500. Once she reaches $3,500, she will pay $240 (20% of $1,200) co-insurance each month until she reaches the combined pharmacy and health plan out-of-pocket maximum of $9,500. Once the out-of-pocket maximum is reached, the plan will pay 100% of all remaining medical and pharmacy expenses for the rest of the year.

Under the Select PPO, she will pay $560 every month ($30 co-pays and $500 co-insurance) until she reaches the prescription-only out-of-pocket maximum of $5,000.

Open Enrollment is the annual opportunity for you to elect the benefits that best meet your needs. All benefits-eligible employees should complete Open Enrollment from Oct. 19 through Nov. 2 for calendar year 2021 benefits. Learn more about Open Enrollment and sign up for 2021 benefits at vu.edu/oe.

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