Pharmacy Benefits
Effective July 1, 2023 to June 30, 2024Our 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. You can also receive a 90-day supply at your local CVS pharmacy, and you won’t have to wait to receive it.
CVS 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 to ensure communication of BCBSTX in-network status to all locations so that Team Members will not experience issues getting prescriptions filled because pharmacists incorrectly notify Team Members that CVS does not accept BCBSTX coverage.
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.
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 |
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 |
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 |