Individual & Family Prescription Drug Benefits

Individual & Family Plans Prescription Drug Benefits

Whether you’re looking for an in-network pharmacy in your area, need to see if a prescription is covered, or want to learn more about your plan’s prescription drug coverage, Healthfirst can help.

Understanding your prescription benefits

Your deductible for prescription drug coverage, and the amount you’ll pay for each prescription, will vary depending on your plan. To see your specific coverage and costs, log in to your account.

Helpful reminders

Healthfirst helps you get healthy, and stay healthy, by providing the medications you need, when you need them.

Your pharmacy coverage

If you have an Essential Plan, a Marketplace (Leaf or Leaf Premier) plan, or Child Health Plus, you have prescription drug coverage included in your plan. Log in to see your plan’s specific coverage details.

Medicaid pharmacy coverage

If you have a Medicaid Managed Care Plan, the State Medicaid NYRx pharmacy program covers your prescription drug benefits.

Learn more at Medicaid NYRx

90-day prescriptions

If you’d like the ease of refilling your medications every three months instead of every month, ask your doctor about 90-day prescriptions. In many cases, they may even cost less per day than 30-day supplies. And with Caremark’s mail-order service, you can get a 90-day supply of certain medications mailed right to your home.

Learn more about Caremark

Factors that determine cost

To better understand how your prescription drug coverage works and what determines various costs, please review the information below.

Generic vs. brand

According to the FDA, generic drugs must have the same active ingredient, strength, quality, and safety as the brand-name drug. So generics are just as safe and effective as brand-name drugs but often cost much less.

Prior authorization

For some prescription medications, your doctor may need to get prior authorization from us before it can be filled. We do this to make sure you don’t get prescribed a drug that could counteract another drug you’re on. We also may request that a generic drug be prescribed over the more expensive brand drug so you can save money.

Out-of-pocket costs

Depending on which Healthfirst plan you have, you may have to pay some out-of-pocket costs for your medications. These costs could include a deductible or a copay and are based on your plan type, drug tiers, and other factors.

Drug tiers

Prescription drugs are grouped into different levels called “tiers”. Depending on your plan, there may be multiple tiers, with Tier 1 (preferred generic drugs) being the lowest-cost tier. Often, the amount you pay depends on the specific drug tier as well as your plan type.

Deductibles

Whether or not you have a deductible depends on the specific plan you have and the specific drug you need. If your plan has a deductible, then you will need to pay the full amount of that prescription medication until you reach your deductible amount. Then, depending on your plan, we’ll pay for some or all of the medication for the rest of the year.

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