2023-2024 Benefits Guide

Prescription Drug Coverage Retail Prescription (copays per 30-day supply) Preferred Generic Drugs Preferred $0 Non-Preferred $10

$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

Non-Preferred Generic Drugs Preferred Brand Drugs

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

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 Non-Preferred Specialty Drugs

$150 per Rx

$250 per Rx $250 plus 50% additional charge Mail Service Prescription (copays per 90-day supply) Deductible does not apply Preferred Generic Drugs No Charge

Non-Preferred Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs

$30 per Rx

100% after cal yr deductible

Not Applicable

Not Applicable

$150 per Rx

$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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