Page 12 - Work Life and Benefits Booklet 2018 - SS A

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

Retail Pharmacy
Present your medical plan ID card at a participating SAVE MONEY ON YOUR MEDICATIONS!
pharmacy. You will receive up to a 30-day supply for your
prescription. You will pay a copay based on the type of Ask for Generic Drugs
prescription you receive. Reference your SBC for cots on You can save money by asking for generic drugs. The
non-preferred drugs. FDA requires that generic drugs have the same high
quality, strength, purity, and stability as brand-name
Mail Order – Maintenance Medication drugs. The next time you need a prescription, ask your
doctor to prescribe a generic drug when it is available
If you take maintenance medications for conditions such as and appropriate.
high blood pressure, asthma or diabetes, BCBSTX’s mail
order program can save you time and money.
Use Mail Order
When using the mail order service, you will receive a 3- If you require regular medication for a long-term or
month (90-day) supply for the cost of 2 months. So you pay chronic condition, such as arthritis, or diabetes, you can
for two and get one free! save money by using your plan’s mail order service.

PLAN NAME BCBSTX HSA 603 BCBSTX PPO MMF7 BCBSTX PPO HIGH 801

NON-
NON-
BLUE CHOICE NON-NETWORK PARTICIPATING PARTICIPATING NON-NETWORK PARTICIPATING PARTICIPATING NON-NETWORK
NETWORK
Retail Copay (30-day supply)
OOPM Embedded in $1,000 / $3,000 $1,000 / $3,000 $1,000 / $3,000 none none none
Generic medical plan $10 Copay $15 Copay $15, 20% $0-10 Copay $10-20 Copay $10-20, 20%
deductible.
Preferred Brand You must pay Same as net- $40 Copay $50 Copay $50, 20% $50 Copay $70 Copay $70, 20%
work and
all RX costs
Non-Preferred up to the de- subject to bal- $75 Copay $85 Copay $70, 20% $100 Copay $120 Copay $120, 20%
Brand ductible, then ance billing
plan pays
Specialty 100% $150 Copay $150 Copay $150, 20% $150-250 Copay $150-250 Copay $150-250, 20%

Mail Order Copay (90-day supply)
Generic Same as net- $30 Copay $30 Copay Not Covered $0-30 Copay $0-30 Copay Not Covered
Preferred Brand Medical plan work and $120 Copay $120 Copay Not Covered $150 Copay $150 Copay Not Covered
deductible
Non-Preferred applies subject to bal-
ance billing
Brand $225 Copay $225 Copay Not Covered $300 Copay $300 Copay Not Covered