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Rx Drug Card

BlueChoicesSM offers four options in a Rx Drug Card. Each option has a deductible and a three-tier benefit. All options can be purchased with or without a deductible waiver.

Option 1: Available with BlueClassic & BluePreferred

Deductible*

$50 per Enrollee (3 per Family) per Calendar Year

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $5 Copayment

Formulary

You pay 20% Copayment

Non-Formulary

You pay 50% Copayment

Option 2: Available with BlueClassic & BluePreferred

Deductible*

$50 per Enrollee (3 per Family) per Calendar Year

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $10 Copayment

Formulary

You pay 20% Copayment

Non-Formulary

You pay 35% Copayment

Option 3: Available with BlueClassic, BluePreferred & BlueEssentials

Deductible*

$100 per Enrollee (3 per Family) per Calendar Year

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $5 Copayment

Formulary

You pay 40% Copayment

Non-Formulary

You pay 50% Copayment

Option 4: Available with BlueClassic, BluePreferred & BlueEssentials

Deductible*

$100 per Enrollee (3 per Family) per Calendar Year

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $10 Copayment

Formulary

You pay 50% Copayment

Non-Formulary

You pay 50% Copayment

*Deductible waiver available to purchase as an optional benefit.

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These options depict drug benefits with deductible waiver purchased

Option 1 with Deductible Waiver: Available with BlueClassic & BluePreferred

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $5 Copayment

Formulary

You pay 20% Copayment

Non-Formulary

You pay 50% Copayment

Option 2 with Deductible Waiver: Available with BlueClassic & BluePreferred

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $10 Copayment

Formulary

You pay 20% Copayment

Non-Formulary

You pay 35% Copayment

Option 3 with Deductible Waiver: Available with BlueClassic, BluePreferred & BlueEssentials

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $5 Copayment

Formulary

You pay 40% Copayment

Non-Formulary

You pay 50% Copayment

Option 4 with Deductible Waiver: Available with BlueClassic, BluePreferred & BlueEssentials

Maximum Copayment

$3,500 per Enrollee per Calendar Year

Generic

You pay $10 Copayment

Formulary

You pay 50% Copayment

Non-Formulary

You pay 50% Copayment

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