Our Prescription Drug Program is coordinated through Blue Cross and Blue Shield of Texas. You may find information on your benefits coverage and search for network pharmacies by logging on to www.bcbstx.com or calling the Customer Care number on your ID Card.
Your cost is determined by the tier assigned to the prescription drug product. All products on the list are assigned as Tier 1, Tier 2 or Tier 3.
Beginning January 1, 2017, all prescription drug copays will apply to the out-of-pocket maximum.
| PPO 750 | ||
| IN-NETWORK | OUT-OF-NETWORK | |
| Rx Deductible | $150 Per Individual; $450 per family. Deductible does not apply to Tier 1 prescriptions. | |
| RETAIL RX (30-DAY SUPPLY) | ||
| Tier 1 | $15 | Not covered |
| Tier 2 | $35 | Not covered |
| Tier 3 | $70 | Not covered |
| Specialty Medication | $150 | N/A |
| MAIL ORDER RX (90-DAY SUPPLY) | ||
| Tier 1 | $30 | N/A |
| Tier 2 | $70 | N/A |
| Tier 3 | $140 | N/A |
| PPO 750 | ||
| IN-NETWORK | OUT-OF-NETWORK | |
| Rx Deductible | $150 Per Individual; $450 per family. Deductible does not apply to Tier 1 prescriptions. | |
| RETAIL RX (30-DAY SUPPLY) | ||
| Tier 1 | $15 | Not covered |
| Tier 2 | $35 | Not covered |
| Tier 3 | $70 | Not covered |
| Specialty Medication | $150 | N/A |
| MAIL ORDER RX (90-DAY SUPPLY) | ||
| Tier 1 | $30 | N/A |
| Tier 2 | $70 | N/A |
| Tier 3 | $140 | N/A |
| PPO 750 | KAISER | |
| IN-NETWORK & OUT-OF-NETWORK | IN-NETWORK | |
| Rx Deductible | Medical deductible applies | None |
| RETAIL RX (30-DAY SUPPLY) | ||
| Tier 1 | Maintenance medications are covered at 100%* | $15 |
| Tier 2 | $35 | |
| Tier 3 | Not Covered | |
| Specialty Medication | Not Covered | |
| MAIL ORDER RX (90-DAY SUPPLY) | ||
| Tier 1 | Maintenance medications are covered at 100%* | $30 |
| Tier 2 | $70 | |
| Tier 3 | Not Covered | |
*All other prescription costs will be applied to the HSA medical deductible.
Note: You may find it more cost effective to utilize the $4/$10 generic program available at many pharmacies. You may also obtain a 90-day supply at retail. You will need to pay the 30-day supply copay times three.
Specialty medications must be obtained through PrimeRx. They will no longer be available through a retail pharmacy. The copay will be $150 per prescription. To order or transfer a specialty Medication or for more information, please call 877-627-MEDS (6337).
If your doctor indicates you may be dispensed a generic medication but you prefer a brand medication, you will have to pay the difference between the cost of the brand and the generic along with the applicable brand copay. Please review the REQUIRED NOTICES for important information regarding the HSA Plan; this coverage is considered Non-Creditable Coverage. This is important to you because it could mean that you may pay a higher premium (penalty) if you do not join a Medicare drug plan when you first become eligible.