Page 11 - AESC 2019 Benefits Gudie

Prescription Drugs

The prescription drug plan is administered by BCBST in partnership with
Express Scripts. Your BCBST member ID may also be used for pharmacy
services.

Similar to the medical plans, the prescription drug plans have in-network
and out-of-network beneits with the exception of the Sharing (EPO)
plan. The participating pharmacy network includes large drug store
chains such as Walgreens and CVS, as well as many independent
pharmacies. The Nissan Family Pharmacy is also in-network. Your cost
for prescription drugs varies depending on the plan you select and the
type of drug used to ill your prescription. Information on participating
pharmacies and drug costs may be found through BlueAccess or on the
myBlue TN mobile app.

BlueCross BlueShield of Tennessee

Savings (HSA) Plan Reimbursement (HRA) Plan Sharing (EPO) Plan
Out-of- Out-of- Out-of-
In-Network Network In-Network Network In-Network Network
Retail Prescription Drugs—Supply Limit 30 Days*
Generic 100% after 100% after 90% no 90% no 90% no N/A
deductible deductible deductible deductible deductible
Preferred 100% after 100% after 75% no 75% no 75% no N/A
Brand deductible deductible deductible deductible deductible
Non-Preferred 100% after 100% after 65% no 65% no 65% no N/A
Brand deductible deductible deductible deductible deductible
Mail Order—Supply Limit 90 Days*
Generic 100% after Not covered $25 copay Not covered $25 copay N/A
deductible
Preferred 100% after Not covered $70 copay Not covered $70 copay N/A
Brand deductible
Non-Preferred 100% after Not covered $140 copay Not covered $140 copay N/A
Brand deductible

* You may receive a 90 day supply of medications at participating Select90 pharmacies . The following national pharmacies are
included: Kroger, Sam’s Club, Wal-Mart . Additional pharmacies can be found under the Find a Doctor link on BlueAccess or on
the myBlue TN App . The Nissan Family Pharmacy is also in the network . All specialty medications must be filled through one of
BCBST’s Specialty Pharmacy network providers . If you select a brand name drug when a generic equivalent is available, the plan
will only pay the cost of the generic drug . The plan will not cover medications for which there is an equivalent over-the-counter
alternative . Please refer to the BCBST 2019 Preferred Formulary and Prescription Drug List for all prior authorization, step
therapy and quantity limits that apply to the plan .

Envision AESC 11