Page 11 - FSSI EE Guide 07-20 - CA

The Blue Shield medical plans include prescription drug coverage for you and your covered dependents.

Retail Pharmacy
Use a retail pharmacy to fill prescriptions for acute conditions (conditions that do not
require the medication to be taken on a regular basis). At a participating pharmacy, you
will receive up to a 30 day supply of your prescriptions.

Mail Order Pharmacy – Maintenance Medication
You could pay less for the same medication when you use the mail order pharmacy. Blue
Shield has partnered with CVS Caremark to provide our mail order drug program.

The mail order pharmacy is a fast, easy and convenient way to save time and money on
your maintenance medications (drugs that you need to take regularly). You can order
additional supplies of medication at a discount. See below for details!

Blue Shield
Blue Shield HMO Blue Shield Blue Shield
Plan Name HMO Trio Access+ PPO PPO HSA
Deductible $0 $0 $0 $0 Plan Deductible Applies
Retail Pharmacy

Tier 1 $15 Copay $15 Copay $15 Copay $15 + 25% $10 Copay $10 + 25%
Tier 2 $30 Copay $30 Copay $30 Copay $30 + 25% $25 Copay $25 + 25%
Tier 3 $30 Copay* $30 Copay* $45 Copay $45 + 25% $40 Copay $40 + 25%
Tier 4 20% Max $200 20% Max $200 30% Max $200 30% Max $200 30% Max $200 30% Max $200
+ 25% + 25%
Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
Tier 1 $30 Copay $30 Copay $30 Copay Not Covered $20 Copay Not Covered
Tier 2 $60 Copay $60 Copay $60 Copay Not Covered $50 Copay Not Covered
Tier 3 $60 Copay* $60 Copay* $90 Copay Not Covered $80 Copay Not Covered
Tier 4 20% Max $400 20% Max $400 30% Max $400 Not Covered 30% Max $400 Not Covered
Supply Limit 90 Days 90 Days 90 Days N/A 90 Days N/A

Specialty (Retail and Mail Order)
Tier 4 Specialty 20% Max $200 20% Max $200 30% Max $200 Not Covered 30% Max $200 Not Covered

Supply Limit 30 Days 30 Days 30 Days N/A 30 Days N/A
*Prior authorization is required

Pharmacy Tips

Save money using generic and over the counter drugs when available.
Generic drugs must use the same active ingredients as the brand name version of the
drug. A generic drug must also meet the same quality and safety standards.

Use the mail order benefit through CVS Caremark for maintenance medications.
To save money and time, consider using the mail order pharmacy to fill your maintenance
medications. Go to www.caremark.com or call (866) 346-7200 to get started.