Prescription Drug FAQs
How does the prescription drug plan work?
With the CDHP/HSA
Your copay/coinsurance for prescriptions count toward your annual medical deductible and out-of-pocket maximum. Except for certain preventive drugs, for which the deductible is waived, you pay the full cost of your prescriptions until you meet your medical deductible.
Once you meet your medical deductible, the costs in the chart below apply in-network. There is no out-of-network coverage.
With the PPO
No deductibles apply in-network. You pay a set copay, as outlined in the chart below.
Out-of-network, you are covered for generic, preferred brand-name and non-preferred brand-name retail drugs only. After you meet your medical deductible, you will pay 50% coinsurance for allowable medications, minus the in-network copay.
In-Network | CDHP/HSA | PPO |
RETAIL (Up to 30-Day Supply) | |
Generic |
You pay a $5 copay, after you meet your medical deductible. | You pay a $15 copay. |
Preferred Brand-Name | You pay 25% coinsurance ($30 minimum, $100 maximum), after you meet your medical deductible. | You pay a $40 copay. |
Non-Preferred Brand-Name | You pay 25% coinsurance ($60 minimum, $125 maximum), after you meet your medical deductible. | You pay a $55 copay. |
Specialty | You pay a $150 copay, after you meet your medical deductible. | You pay a $150 copay. |
MAIL ORDER (90-Day Supply) | |
Generic | You pay a $12.50 copay, after you meet your medical deductible. | You pay a $30 copay. |
Preferred Brand-Name | You pay 25% coinsurance ($75 minimum, $250 maximum), after you meet your medical deductible. | You pay a $80 copay. |
Non-Preferred Brand-Name | You pay 25% coinsurance ($150 minimum, $312.50 maximum), after you meet your medical deductible. | You pay a $110 copay. |
Keep in mind:
The prescription drug benefit does not cover brand-name proton pump inhibitors (PPIs). PPIs are a class of drugs used to treat conditions associated with acid reflux disease or ulcers. Brand-name PPIs include Aciphex®, Dexilant®, Kapidex®, Nexium®, Prevacid®, Prevacid® Solutab, Prilosec®, Protonix® and Zegerid®.
If a generic drug is available and a brand-name drug is dispensed, you pay the brand-name copay/coinsurance plus the difference in cost between the generic and the brand-name drug. This difference is an excluded benefit.
Prior authorization is required before certain high-cost medications and those with potential for misuse are covered by the pharmacy plan. Your doctor is required to submit a request for coverage through Prime Therapeutics for these drugs.
Compound drugs are not covered for participants over the age of 13. Ask your doctor if there is an alternative, non-compounded drug that is right for you.
Specialty drugs are covered only if received by mail-order through the Prime Therapeutics Specialty Pharmacy. For new prescriptions, have your doctor call 877-627-6337 to receive pharmacy approval for coverage.
As a CDHP participant, am I eligible for in-network prescription discounts while meeting the deductible?
Yes, you’ll use your BlueCross BlueShield of Texas ID card to fill prescriptions. With the card, you can receive network discounts at the pharmacy even while meeting your deductible. Also, if your prescription drugs are classified as preventive (and on the covered list), the deductible is waived under the CDHP.
Which drugs are considered preventive?
With both the PPO and CDHP options, certain preventive drugs are covered at 100%. Preventive drugs include:
Antihypertensives (high blood pressure)
Asthma/COPD
Contraceptives
Diabetes medication
Fluoride supplements
Lipid-lowering agents
Osteoporosis drugs
Pediatric vitamins with fluoride
Prenatal vitamins
Respiratory
Smoking cessation
How can I find out if my prescription is considered generic, preferred brand-name or non-preferred brand-name, as well as what the costs are?
You can log on the BCBSTX or Prime Therapeutics Web sites at
www.bcbstx.com/ahbelo or
www.myprime.com. Search for information on your prescription drugs, generic alternatives, costs, pharmacy providers in your area, mail-order options and more.
How do I find a participating pharmacy?
Find a Pharmacy
BCBS Texas (regardless of the state where you reside)
BCBSTX — Non-HMO Network
What is the process for filling prescriptions?
Retail prescriptions
Your BCBSTX ID card will work for both medical and pharmacy. When you need to fill a prescription, simply present your BCBSTX ID card at your pharmacy.
Mail-order prescriptions
To use the mail-order program for the first time:
For each maintenance or long-term medication prescribed for you, ask your physician to write two prescriptions:
One to be filled at a participating local pharmacy for immediate use (typically a 30-day supply with no refills)
One for the maximum-day supply your health plan allows to be filled at PrimeMail Pharmacy (typically a 90-day supply with three refills)
Complete (in black ink) the
Prime Rx Mail-Order Form. You may also obtain a form by contacting a Member Services Agent at 877-35-PRIME
(1-877-357-7463).
Mail to PrimeMail Pharmacy:
Your completed Prime Rx Mail-Order Form
Your original, physician-signed, maximum-day supply prescription*
The appropriate payment*
*You may submit multiple prescriptions and payments in one order.
You can order refills using the phone, Internet or mail. Remember to order three weeks before your current prescription is due to run out.
Refill by phone
Dial PrimeMail’s automated refill line at 1-877-35-PRIME (1-877-357-7463).
Have your prescription number and credit card information ready. Follow the system prompts to complete your refill order.
Refill by Internet
Follow the instructions to complete your refill order. Have your prescription number and credit card information ready.
Refill by mail
Fill out the
Prime Rx Mail-Order Form. Order forms are also included with each PrimeMail Pharmacy prescription delivery.
Include the appropriate payment. Orders placed by mail can be paid for by check, credit card or money order. U.S. Postal regulations prohibit sending cash through the mail. Please do not send cash with your order.
Send your refill orders to the following address:
PrimeMail Pharmacy
P.O. Box 650041
Dallas, TX 75265-0041