Page 7 - 2018 CareHere Enrollment

CareHere

Prescription Drugs

The participating pharmacy network includes large drug store chains
such as Walgreens and CVS, as well as many independent pharmacies.
Your copayment for preventive prescriptions vary depending on the type
of drug used to ill your prescription. Non-preventive prescriptions are
subject to the calendar year deductible and out-of-pocket maximum.

BCBST BCBST
Provided by SAV-RX Option 1—TN Only Option 2
Network S Network P
Prescription Drugs*

Retail 30-Day Supply
Generic $5 copay preventive Rx; $5 copay preventive Rx;
all other—20% after all other—20% after
deductible deductible
Preferred Brand $25 copay preventive $25 copay preventive
Rx; all other—20% after Rx; all other—20% after
deductible deductible
Non-Preferred Brand $50 copay preventive $50 copay preventive
Rx; all other—20% after Rx; all other—20% after
deductible deductible
Mail Order 90-Day Supply
Generic $5 copay per 30 day $5 copay per 30 day
supply preventive Rx; supply preventive Rx;
all other Rx—20% after all other Rx—20% after
deductible deductible
Preferred Brand $25 copay per 30 day $25 copay per30 day
supply preventive Rx; supply preventive Rx;
all other Rx—20% after all other Rx—20% after
deductible deductible
Non-Preferred Brand $50 copay per 30 day $50 copay per 30 day
supply preventive Rx; supply preventive Rx;
all other Rx—20% after all other Rx—20% after
deductible deductible

* If you select a brand name drug when a generic equivalent is available, the plan will only pay
the cost of the generic drug.

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