Page 7 - 2017 Benefits Enrollment

Prescription Drugs 2017 Beneits Enrollment

The prescription drug plan is administered by Express Scripts Pharmacy. Similar
to the medical plan, the prescription drug plan has in-network and out-of-network
beneits. The participating pharmacy network includes large drug store chains such
as Walgreens and CVS, as well as many independent pharmacies. Your copayment
for prescription drugs varies depending on the type of drug used to ill your
prescription.

BCBS TX
HDHP 2000 HDHP 3000 PPO 1000
In-Network In-Network In-Network
Prescription Drugs
Deductible Medical deductible Medical deductible None
applies applies
Step Therapy Applies Applies Applies
Retail—Up to a 90-Day Supply
Tier 1—Generic 90% after ded 80% after ded $10 copay
Tier 2—Preferred Brand 90% after ded 80% after ded $25 copay
Tier 3—Non-Pref Brand 90% after ded 80% after ded $50 copay
Mail Order—Up to a 90-Day Supply
Tier 1—Generic 90% after ded 80% after ded $20 copay
Tier 2—Preferred Brand 90% after ded 80% after ded $50 copay
Tier 3—Non-Pref Brand 90% after ded 80% after ded $100 copay

Medications are limited to those included on Express Scripts National Preferred
TClass drug formulary; visit www.express-scripts.com/NATPLSNATPREF14.

Specialty medications are limited to a 30-day supply and must be illed through the
Express Scripts specialty pharmacy. The initial ill of a specialty medication may be
obtained at a retail pharmacy.

Certain prescriptions require prior authorization, require the use of lower cost
therapeutic equivalent medications, and/or have quantity limits. Contact the Express
Scripts member services number at the back of this guide for further details.

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