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copay

Prescription Drug Care

Co-payments & Deductibles

Plan A

Prescription Type Retail Network

Retail
Non-network

Mail Order
Type 1 (Generic) $10 copay 50% after copay $20 copay
Type 2 (Name Brand) $30 copay 50% after copay $60 copay
Type 3 (Higher Priced Name Brand) $50 copay 50% after copay $100 copay

QHDP

Prescription Type Retail Network

Retail
Non-network

Mail Order
Type 1 (Generic) Annual Deductible then 100% Annual Deductible then 50% Annual Deductible then 100%
Type 2 (Name Brand) Annual Deductible then 100% Annual Deductible then 50% Annual Deductible then 100%
Type 3 (Higher Priced Name Brand) Annual Deductible then 100% Annual Deductible then 50% Annual Deductible then 100%

Tier 1 Contraceptives covered at 100% under both plans (not subject to deductible)

If you have a question about prescription benefits, please contact Blue Cross Blue Shield customer service at 800-228-1436.