Prescription Drug Benefits

Here is a snapshot of your prescription drug benefits and what you pay:

For more information on your prescription drug benefits, the drug cost category for your prescription (generic, preferred, non-preferred or specialty), and mail-order programs, please visit the Prime Therapeutics website or the Kaiser website.

 
Prime Therapeutics1
Kaiser Permanente
BCBSTX HSA2
BCBSTX PPO
KAISER HMO
Generic
Retail In-Network:
15% coinsurance after deductible		 In-Network:
$4 copay		 In-Network:
$15 copay
(100-day supply)
Mail Order 15% coinsurance after deductible
(90-day supply)		 $10 copay
(90-day supply)		 $30 copay
(100-day supply)
Preferred Brand
Retail 15% coinsurance after deductible In-Network:
20% coinsurance
($40 min/$85 max copay)		 In-Network:
$35 copay
(100-day supply)
Mail Order 15% coinsurance after deductible
(90-day supply)		 20% coinsurance
($80 min/$170 max copay)
(90-day supply)		 $70 copay
(100-day supply)
Non-preferred Brand
Retail In-Network:
15% coinsurance after deductible		 In-Network:
50% coinsurance
($80 min/$170 max copay)		 Same as Preferred Brand drugs when approved in advance through an exception review.
Mail Order 15% coinsurance after deductible
(90-day supply)		 50% coinsurance
($160 min/$200 max copay)
(90-day supply)		 Same as Preferred Brand drugs when approved in advance through an exception review.
Specialty Drugs (Preferred)
Retail In-Network:
15% coinsurance after deductible		 In-Network:
20% coinsurance
($40 min/$85 max copay)		 30% coinsurance
($250 maximum)
Mail Order 15% coinsurance after deductible
(90-day supply)		 20% coinsurance
($80 min/$170 max copay, prorated for less than 90-day supply)		 30% coinsurance
($250 maximum)
Specialty Drugs (Non-Preferred)
Retail In-Network:
15% coinsurance after deductible		 In-Network:
50% coinsurance
($160 min/$200 max copay)		 30% coinsurance
($250 maximum)
Mail Order 15% coinsurance after deductible
(90-day supply)		 50% coinsurance
($160 min/$200 max copay, prorated for less than 90-day supply)		 30% coinsurance
($250 maximum)

(1) Any additional costs that you pay under the following plan provisions a) will not apply to your annual deductible or annual out-of-pocket maximum; b) will not be subject to the maximum copayment per prescription (PPO Plan)

  • Express Scripts Pharmacy Mail Order: After three, 30-day fills at a retail pharmacy, you will need to refill your maintenance medication prescriptions with Express Scripts Pharmacy Mail Order or you will pay the full cost of the medication. You can also fill your 90-day prescription at any Walgreens retail pharmacy in the U.S.
  • Generic preferred: If you obtain a brand-name drug when an equivalent generic drug is available, you will pay the brand name copayment (or coinsurance) plus 100% of the difference in cost. This additional cost applies regardless of whether your doctor prescribes a brand-name drug.

(2) The BCBSTX HSA Plan covers certain preventive prescription drugs—like insulin and blood pressure medicine—at 85% before the plan deductible. You pay 15% coinsurance for these medicines—even if you haven’t satisfied the annual plan deductible. However, the coinsurance you pay for preventive prescription drugs does not count toward meeting the BCBSTX HSA annual deductible.