Prescription Order & Claim Forms

Plan For Your Prescription Drugs*
HMO Illinois

You pay a flat-dollar amount (copayment), as follows:

Retail (one-month supply)

$10 generic/$30 preferred brand/$60 nonpreferred brand

Home delivery (three-month supply)

$20 generic/$60 preferred brand/$120 nonpreferred brand
Premier PPO
Select PPO
Value PPO

You pay the full cost until you reach the annual deductible.

After that, you pay 20% (coinsurance) of the drug's cost, up to the annual out-of-pocket maximum.

* If a generic alternative to your medication is available, but you opt for the brand version, your out-of-pocket costs will be higher.