2022 - 2023 Benefits Guide

Prescription Drug Coverage

Retail Prescription (copays per 30-day supply)

Preferred $0 Non-Preferred $10 Preferred $10 Non-Preferred $20 Preferred $50 Non-Preferred $70

$10 plus 50% additional charge $20 plus 50% additional charge $70 plus 50% additional charge $120 plus 50% additional charge $150 plus 50% additional charge $250 plus 50% additional charge

Preferred Generic Drugs

Non-Preferred Generic Drugs

Preferred Brand Drugs

No charge after deductible plus 50% additional charge

100% after cal yr deductible

Preferred $100 Non-Preferred $120

Non-Preferred Brand Drugs

Preferred Specialty Drugs

$150 per Rx

Non-Preferred Specialty Drugs

$250 per Rx

Mail Service Prescription (copays per 90-day supply) Deductible does not apply

Preferred Generic Drugs

No Charge

Non-Preferred Generic Drugs

$30 per Rx

100% after cal yr deductible

Not Applicable

Not Applicable

Preferred Brand Drugs

$150 per Rx

Non-Preferred Brand Drugs

$300 per Rx

More information about prescription drug coverage is available at https://www.bcbstx.com/rx-drugs/drug- lists/drug-lists

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