Rx Drug Card Information for Employers

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Rx Drug Card

BlueChoices^SM 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.

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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