Pharmacy Benefits
Save Time & Money on Your PrescriptionsPrescription Drug Coverage
Plan Highlights
Our BCBSTX medical plans use the Prime Therapeutics Balanced Drug List Formulary, which is a list of preferred drugs that cost you less. If your doctor writes you a prescription, make sure it’s on the formulary, and if it’s not, ask your doctor whether another drug on the formulary will work for you.
- You can fill one prescription for a maintenance medication at a retail pharmacy before the home delivery requirement applies.
- You have the option to get 90-day supplies at CVS Pharmacy locations.
- If you’re enrolled in the Choice HSA, you can use your HSA to pay for prescription drugs.
Note: If you’re enrolled in the Kaiser HRA plan, you must fill your prescriptions at a Kaiser-associated pharmacy in order for them to be covered. You can use your HRA to pay for prescription drugs.
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Retail Pharmacies
Retail pharmacies are best for filling medications that you’ll use for 30 days or less. You can get your medication and begin using it almost immediately. You can also receive a 90-day supply at your local CVS pharmacy, and you won’t have to wait to receive it.
CVS Pharmacy is In-Network
- CVS Pharmacy is in-network for BCBSTX and will fill your prescriptions.
- If your CVS Pharmacy is one that doesn’t immediately recognize your plan, you can request that they process your ID card again to confirm.
- Michaels and BCBSTX are working with CVS Pharmacy to ensure communication of the BCBSTX in-network status to all CVS Pharmacy locations so that Team Members will not experience issues getting prescriptions filled due to pharmacists incorrectly notifying Team Members that CVS does not accept BCBSTX coverage.
90-Day Home Delivery Prescriptions
Home delivery prescriptions are best for filling medications that you’ll take for 90 days or more.
- Make sure you ask your doctor to write the prescription for 90 days instead of 30.
- Your doctor may be able to upload your prescription directly to the prescription drug provider. Otherwise, you must complete a Home Delivery Service Form in the BCBSTX member portal and send in your written prescription.
- It can take up to two weeks for you to receive your medication using this method. If you need medication immediately, ask your doctor for a 30-day prescription that you can fill at your local pharmacy.
For maintenance medications, 90-day home delivery is required. Refer to the next section for more details.
Maintenance Medications
Maintenance medications are prescriptions that you need on a regular basis for an ongoing condition, such as high blood pressure.
Maintenance medications on the preventive drug list are available for $0 copay with no deductible.
90-Day Home Delivery Requirement
If you are enrolled in a BCBSTX plan and you take a maintenance medication, it is mandatory that you use 90-day home delivery. You will be allowed one 30-day fill at a pharmacy location. After that, you’re required to get a 90-day supply either through mail order or at a local CVS Pharmacy.
In-Network Benefits
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| BCBSTX Choice HSA | BCBSTX Basic PPO | BCBSTX Enhanced PPO | Kaiser HRA | |
|---|---|---|---|---|
| In-Network Benefits Only | ||||
| Preventive Drug List1 | $0 copay | $0 copay | $0 copay | $0 (based on ACA required coverage) |
| Generic | Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 20% | Retail2: $14 copay Mail-order3: $35 copay | Retail2: $10 copay Mail-order3: $20 copay | Retail2: $10 copay Mail-order3: $20 copay |
| Preferred Brand | Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 20% | Retail2: 25% ($50 min; $130 max) Mail-order3: $125 copay | Retail2: $35 copay Mail-order3: $70 copay | Retail2: $30 copay Mail-order3: $60 copay |
| Non-Preferred Brand4 | Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 50% ($100 min; $250 max) | 50% after deductible ($100 min; $250 max) | 50% after deductible ($100 min; $250 max) | Retail2: $30 copay Mail-order3: $60 copay |
| Specialty Pharmacy5 | Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay: Generic: 20% ($200 max) Preferred brand: 20% ($250 max) Non-Preferred brand: 50% ($350 max) | Generic: $14 copay | Generic: $10 copay | $30 copay in most cases |
| Preferred brand: 25% ($50 min; $130 max) | Preferred brand: $35 copay | |||
| Non-Preferred brand: 50% after deductible ($350 max) | Non-Preferred brand: Non-Preferred brand: 50% after deductible ($350 max) |
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| Out-of-Pocket Maximum (If you reach this limit, Michaels pays 100% of all remaining eligible prescription drug costs for the rest of the plan year). | ||||
| Individual | Included in medical out-of-pocket max | $2,050 | Included in medical out-of-pocket max | Included in medical out-of-pocket max |
| Family | Included in medical out-of-pocket max | $4,100 | Included in medical out-of-pocket max | Included in medical out-of-pocket max |
| 1Review the preventive drug list. 2Up to 30-day supply. 3With BCBSTX plans, up to 90-day supply; also available at your local CVS pharmacy, the same as through mail order. The Kaiser HRA allows up to a 100-day supply. 4Non-preferred brand drug costs don’t apply to the out-of-pocket-maximum. Up to a 30-day supply. Specialty drug costs apply to out-of-pocket-maximum. |
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Helpful Resources
Split-Fill Program
For no additional cost, eligible Team Members can take advantage of the Specialty Drug Split-Fill program to try a partial quantity of a newly prescribed specialty drug before the full month’s supply is filled.
Drug Lists
- Balanced Drug List Formulary (includes Dispensing Limits, Prior Authorization Programs, and Step Therapy Programs)
- Contraceptive List (ACA)
- Drug List (ACA)
- Specialty Drug List