Page 11 - Wire Works 2020 Benefit Guide

Benefits 90-day retail network * In-network mail order In-network Out-of-network
pharmacy provider pharmacy(not part of pharmacy
the 90-day retail
network)
Tier 2 - 1 to 30-day After deductible, you pay After deductible, you pay $40 After deductible, you pay $40 After deductible, you pay $40
Preferred period $40 copay copay copay copay plus an additional 20%
brand-name of BCBSM approved amount
drugs for the drug
31 to 60-day No coverage After deductible, you pay $80 No coverage No coverage
period copay

61 to 83-day No coverage After deductible, you pay No coverage No coverage
period $110 copay
84 to 90-day After deductible, you pay After deductible, you pay No coverage No coverage
period $110 copay $110 copay
Tier 3 - 1 to 30-day After deductible, you pay After deductible, you pay $80 After deductible, you pay $80 After deductible, you pay $80
Nonpreferred period $80 copay copay copay copay plus an additional 20%
brand-name of BCBSM approved amount
drugs for the drug
31 to 60-day No coverage After deductible, you pay No coverage No coverage
period $160 copay

61 to 83-day No coverage After deductible, you pay No coverage No coverage
period $230 copay
84 to 90-day After deductible, you pay After deductible, you pay No coverage No coverage
period $230 copay $230 copay
Tier 4 - 1 to 30-day After deductible, you pay After deductible, you pay After deductible, you pay After deductible, you pay 15%
Generic and period 15% of approved amount, 15% of approved amount, 15% of approved amount, of approved amount, but no
preferred but no more than $150 but no more than $150 but no more than $150 more than $150 plus an
brand-name additional 20% of BCBSM
specialty drugs approved amount for the drug
31 to 60-day No coverage No coverage No coverage No coverage
period
61 to 83-day No coverage No coverage No coverage No coverage
period
84 to 90-day No coverage No coverage No coverage No coverage
period
Tier 5 - 1 to 30-day After deductible, you pay After deductible, you pay After deductible, you pay After deductible, you pay 25%
Nonpreferred period 25% of approved amount, 25% of approved amount, 25% of approved amount, of the approved amount, but
brand-name but no more than $300 but no more than $300 but no more than $300 no more than $300 plus an
specialty drugs additional 20% of the BCBSM
approved amount for the drug
31 to 60-day No coverage No coverage No coverage No coverage
period
61 to 83-day No coverage No coverage No coverage No coverage
period
84 to 90-day No coverage No coverage No coverage No coverage
period

* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers

BV P GBC SG;SBHSA-GBCW/RXSG;SBHSA1500/20 20

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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