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copay

Prescription Drug Care

Co-payments & Deductibles

UCM Custom Plan - EPO

Prescription Type Retail Network

Retail
Non-network

Mail Order
Type 1 (Generic) $10 copay No coverage $20 copay
Type 2 (Name Brand) $50 copay No coverage $100 copay
Type 3 (Higher Priced Name Brand) $75 copay No coverage $150 copay

 

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) 40% up to $50 40% coinsurance 40% up to $100
Type 3 (Higher Priced Name Brand) 60% up to $75 60% coinsurance 60% up to $150

QHDP

Prescription Type Retail Network

Retail
Non-network

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

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

If you have a question about prescription benefits, please contact Blue Cross Blue Shield customer service at 800-654-0155.