How Prescription Drug Benefits Work
Short-Term Prescriptions
For short-term prescriptions (30-day supply), you can fill your prescriptions through network pharmacies. Find the nearest network pharmacy by visiting bcbstx.com or calling the Customer Care number on your ID card.
Long-Term Prescriptions
Maintenance drugs are drugs you take for long-term or chronic conditions, such as insulin for diabetes or blood pressure medication. BCBSTX Base and Buy-Up medical plans and the Kaiser HMO offer savings when you get 90-day supplies of these medications.
You have two ways to get your prescriptions:
- Mail order. Your medications will be delivered directly to you at home. To get started, visit bcbstx.com, or call the Customer Care number on your ID card.
- Pick up at a network pharmacy. Find one near you by visiting bcbstx.com or by calling the Customer Care number on your ID card.
BCBSTX Prescription Drug Coverage at a Glance
Here’s what you pay when you get a prescription filled through the BCBSTX Base or Buy-Up medical plan. Your cost is determined by the tier assigned to the prescription drug: Generic, Formulary Brand, Non-Formulary Brand, or Specialty Drugs.
| Base Plan with Difference Card | Buy-Up Plan with Difference Card | |
| In-Network | In-Network | |
| Mail Order Rx (90-day supply) and Retail Rx (30-day supply) | ||
| Generic | 20% after first $4,500 employee /$9,000 family | 20% after first $6,000 employee/$12,000 family |
| Formulary Brand* | ||
| Non-Formulary Brand | ||
| Specialty Drugs | ||
*The formulary drug list is updated annually, and medications may be added or removed. Before you fill a prescription, view the list or talk with your pharmacist to be sure you are getting a formulary brand or a generic option, if available.
Kaiser HMO Prescription Drugs at a Glance (California Only)
Prescription drug benefits are provided by the HMO. Here’s what you pay when you need a prescription filled. For more details, visit kp.org or call 800‑464‑4000.
| Kaiser HMO (California only) | ||
| Retail (Up to 30-day supply) |
Mail-Order (Up to 100-day supply) |
|
| Prescription drug deductible | None | |
| Generic | $15 copay | $30 copay |
| Formulary Brand | $35 copay | $70 copay |
| Specialty | 30% ($250 maximum) | N/A |
| Out-of-pocket maximum | Combined with medical: $2,000 individual $4,000 family |
|
Two Simple Ways To Save Money
- Ask about generics. When your doctor prescribes a medication, find out if there’s a generic available. Generic drugs use the same active ingredients as brand-name equivalents but cost about 80–85% less. If there’s no generic available, check to see if the medication is on your prescription drug plan’s preferred drug list.
- Shop around. Pharmacies charge different amounts for drugs, and the costs can vary widely. Use goodrx.com to get cost estimates before you fill your prescription.
