Page 13 - Sea Dwelling EE Guide 01-20

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. 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!

Option 1 Option 2 Option 3 Option 4

Blue Shield Blue Shield Blue Shield Blue Shield
Silver Trio Gold Trio Gold Trio Gold Access+
Plan Name 2350/65 HMO 1500/35 HMO 500/35 HMO 1500/35 HMO

$100 / $200
$100 / $200
$350 / $700
Deductible Waived for Tier 1 Waived for Tier 1 $0 Waived for Tier 1
Retail Pharmacy (30 Day Supply Limit)
Tier 1 A/B $20/$25 Copay $15/$20 Copay $15/$20 Copay $15 Copay
Tier 2 A/B $85/$110 Copay $35/$55 Copay $35/$55 Copay $35 Copay
Tier 3 A/B $115/$165 Copay $55/$85 Copay $55/$85 Copay $55 Copay
Tier 4 A/B 45% Max $250 20% Max $250 20% Max $250 20% Max $250

Mail Order Pharmacy (90 Day Supply Limit)
Tier 1 $40 Copay $30 Copay $30 Copay $30 Copay
Tier 2 $170 Copay $70 Copay $70 Copay $70 Copay
Tier 3 $230 Copay $110 Copay $110 Copay $110 Copay
Tier 4 45% Max $500 20% Max $500 20% Max $500 20% Max $500
Option 5 Option 6 Option 7

Blue Shield Blue Shield Blue Shield
Gold Access+ Silver Full Gold Full
Plan Name 500/35 HMO 2300/45 PPO 500/30 PPO
$300 / $600
Deductible $0 Waived for Tier 1 Waived for Tier 1
$100 / $200
Retail Pharmacy (30 Day Supply Limit)
Tier 1 $15 Copay $20 Copay $15 Copay
Tier 2 $35 Copay $75 Copay $50 Copay
Tier 3 $55 Copay $115 Copay $80 Copay
Tier 4 20% Max $250 40% Max $250 30% Max $250
Mail Order Pharmacy (90 Day Supply Limit)
Tier 1 $30 Copay $40 Copay $30 Copay
Tier 2 $70 Copay $150 Copay $100 Copay
Tier 3 $110 Copay $230 Copay $160 Copay
Tier 4 20% Max $500 40% Max $500 30% Max $500