Pharmacy Benefits

Effective July 1, 2023 to June 30, 2024

Our BCBSTX medical plans use the Prime Therapeutics Balanced Drug List Formulary, a list of preferred drugs that cost you less.

If your doctor writes you a prescription, make sure it’s on the formulary. If it’s not, ask your doctor whether another drug on the formulary will work for you.

If you’re enrolled in a BCBSTX plan, you can fill one prescription for a maintenance medication at a retail pharmacy before the home delivery requirement applies. You also 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.

If you’re enrolled in the Kaiser HRA plan, you must fill your prescriptions at a Kaiser pharmacy for them to be covered. You can use your HRA to pay for prescription drugs.

Go to a Retail Pharmacy

Retail pharmacies are best for filling medications you’ll use for 30 days or less. You can get your medication and begin using it almost immediately.

Get a 90-Day Home Delivery Prescription

Home Delivery prescriptions are best for filling medications you’ll take for 90 days or more. Make sure you ask your doctor to write the prescription for 90 days. He/she may be able to upload the prescription directly to the prescription drug provider. If not, you must complete a home delivery service form (on the Michaels BCBSTX website) and send in your written prescription.

This option can take up to two weeks to receive your medication. If you need medication immediately, ask your doctor for a 30-day prescription you can fill at your local pharmacy. Or, you can also receive a 90-day supply at your local CVS pharmacy, and you won’t have to wait to receive it.

Maintenance Medications

If you take maintenance medications (prescriptions you need on a regular basis for an ongoing condition, such as high blood pressure), using home delivery is mandatory if you enroll in a BCBSTX plan. You will be allowed one 30-day fill at a pharmacy location. After that, you’re required to get a 90-day supply through mail order or at a local CVS Pharmacy. Maintenance medications on the preventive drug list are available for $0 copay with no deductible.

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In-Network Benefits

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
Preferred brand: 25% ($50 min; $130 max)
Non-Preferred brand:
50% after deductible ($350 max)		 Generic: $10 copay
Preferred brand: $35 copay
Non-Preferred brand:
50% after deductible ($350 max)		 $30 copay in most cases
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 maximum Included in medical out-of-pocket max
1. Review the preventive drug list here.
2. Up to 30-day supply.
3. With 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.
4. Non-preferred brand drug costs don’t apply to the out-of-pocket-maximum.
5. Up to a 30-day supply. Specialty drug costs apply to out-of-pocket-maximum.

2022-2023 Plan Information

Provider

Mail Order Pharmacy