Page 10 - 2015 OE Sample Guidebook
P. 10
PRESCRIPTION DRUG BENEFITS
Medication HRA Plan HSA Plan
Retail 30-Day Supply
Both medical plans cover prescription Tier 1— Generic $10 copay 20% after deductible*
drugs. There are four coverage Tier 2—Formulary
levels. Your cost is lowest for generic $25 copay 20% after deductible*
medications and higher for brand-name Tier 3—Non-Formulary $50 copay 20% after deductible*
drugs. Tier 4—Specialty $75 copay 20% after deductible*
The program is formulary based. Mail Order 90-Day Supply
Formulary based drugs are selected Tier 1— Generic $30 copay 20% after deductible*
by Blue Cross Blue Shield based upon Tier 2—Formulary $75 copay 20% after deductible*
the recommendations of a committee, Tier 3—Non-Formulary $150 copay 20% after deductible*
which is made up of current and
previously practicing physicians and Copays apply at in-network participating retailers.
pharmacists from across the country. * The HSA Plan will cover prescriptions at 100% after your annual out-of-pocket
The committee considers drugs maximum is reached
regulated by the U.S. Food and Drug
Administration (FDA) for inclusion on Reminder! The prescription drug program requires you to pay
the formulary. Refer to www.bcbsil.com the difference between the generic and brand name costs if you
for the most up to date formulary list.
And as always, consult your physician. choose a brand name drug when a generic is available. You will be
charged the generic copay plus the difference in cost up to the $200
maximum. If the doctor writes the prescription to “Dispense as
Written,” you will not be penalized. In addition, when you switch
from a brand name drug to a generic drug, your irst copay will be
waived as part of the “$0 generic program.”
Some prescriptions will require prior authorization for certain
categories such as Hepatitis C, Oral Fentanyl, Anabolic Steroids,
Attention Deicit Hyperactivity Disorder, Narcolepsy, and Growth
Hormones.
Specialty medications including those used in treatment of
complex medical conditions, such as hepatitis, hemophilia, multiple
sclerosis, rheumatoid arthritis, and other conditions requiring self-
administered injections, will be through Prime Specialty, which is
part of BCBS’s contracting pharmacy network.
The mail order program is designed for participants with
maintenance medications—for heart conditions, allergies, high
blood pressure, diabetes, etc. With the mail order program, you can
receive a convenient 90-day supply of your medication.
10
Medication HRA Plan HSA Plan
Retail 30-Day Supply
Both medical plans cover prescription Tier 1— Generic $10 copay 20% after deductible*
drugs. There are four coverage Tier 2—Formulary
levels. Your cost is lowest for generic $25 copay 20% after deductible*
medications and higher for brand-name Tier 3—Non-Formulary $50 copay 20% after deductible*
drugs. Tier 4—Specialty $75 copay 20% after deductible*
The program is formulary based. Mail Order 90-Day Supply
Formulary based drugs are selected Tier 1— Generic $30 copay 20% after deductible*
by Blue Cross Blue Shield based upon Tier 2—Formulary $75 copay 20% after deductible*
the recommendations of a committee, Tier 3—Non-Formulary $150 copay 20% after deductible*
which is made up of current and
previously practicing physicians and Copays apply at in-network participating retailers.
pharmacists from across the country. * The HSA Plan will cover prescriptions at 100% after your annual out-of-pocket
The committee considers drugs maximum is reached
regulated by the U.S. Food and Drug
Administration (FDA) for inclusion on Reminder! The prescription drug program requires you to pay
the formulary. Refer to www.bcbsil.com the difference between the generic and brand name costs if you
for the most up to date formulary list.
And as always, consult your physician. choose a brand name drug when a generic is available. You will be
charged the generic copay plus the difference in cost up to the $200
maximum. If the doctor writes the prescription to “Dispense as
Written,” you will not be penalized. In addition, when you switch
from a brand name drug to a generic drug, your irst copay will be
waived as part of the “$0 generic program.”
Some prescriptions will require prior authorization for certain
categories such as Hepatitis C, Oral Fentanyl, Anabolic Steroids,
Attention Deicit Hyperactivity Disorder, Narcolepsy, and Growth
Hormones.
Specialty medications including those used in treatment of
complex medical conditions, such as hepatitis, hemophilia, multiple
sclerosis, rheumatoid arthritis, and other conditions requiring self-
administered injections, will be through Prime Specialty, which is
part of BCBS’s contracting pharmacy network.
The mail order program is designed for participants with
maintenance medications—for heart conditions, allergies, high
blood pressure, diabetes, etc. With the mail order program, you can
receive a convenient 90-day supply of your medication.
10
