Blue Preferred Rx Prescription Drug Coverage
Benefits-at-a-Glance City of Saginaw
This is intended as an easy to read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan.
Note: Effective October 1, 2006, the mail order pharmacy for specialty drugs changed to Option Care, an independent company. Specialty prescription drugs (such as Enbrelâ and Humiraâ) are used to treat complex conditions such as rheumatoid arthritis. These drugs require special handling, administration or monitoring. Option Care will handle mail order prescriptions only for specialty drugs while many retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Medco. (Medco is an independent company providing pharmacy benefit services for Blue members.) A list of specialty drugs is available on our Web site at bcbsm.com. Log in under “I am a Member.” If you have any questions, please call Option Care customer service at 865-515-1355.
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90-day retail network pharmacy |
Network mail order provider |
Network pharmacy (not part of the 90-day retail network) |
Non-network pharmacy |
Member’s responsibility (copays) |
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Generic or prescribed over-the-counter drugs |
1 to 34-day period |
$10 copay |
$10 copay |
$10 copay |
$10 copay plus 25% of the BCBSM approved amount for the drug |
35 to 83-day period |
No coverage |
$10 copay |
No coverage |
No coverage |
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84 to 90-day period |
$10 copay |
$10 copay |
No coverage |
No coverage |
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Brand-name drugs |
1 to 34-day period |
$40 copay |
$40 copay |
$40 copay |
$40 copay plus 25% of the BCBSM approved amount for the drug |
35 to 83-day period |
No coverage |
$40 copay |
No coverage |
No coverage |
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84 to 90-day period |
$40 copay |
$40 copay |
No coverage |
No coverage |
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Note: If your prescription is filled by any type of network pharmacy, and you request the brand-name drug when a generic equivalent is available on the BCBSM MAC list and the prescriber has not indicated “Dispensed as Written” (DAW) on the prescription, you must pay the difference in cost between the brand-name drug dispensed and the maximum allowable cost for the generic plus the applicable copay.
Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law.
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*90-day retail network pharmacy |
**Network mail order provider |
Network pharmacy (not part of the 90-day retail network) |
Non-network pharmacy |
Covered Services |
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“Rx only” drugs |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 75% less plan copay |
Prescribed over-the-counter drugs – when covered by BCBSM |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 75% less plan copay |
State-controlled drugs |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 100% less plan copay |
Covered – 75% less plan copay |
Disposable needles and syringes – when dispensed with insulin or other covered injectable legend drugs |
Covered – 100% less plan copay for the insulin or other covered injectable legend drug |
Covered – 100% less plan copay for the insulin or other covered injectable legend drug |
Covered – 100% less plan copay for the insulin or other covered injectable legend drug |
Covered – 75% less plan copay for the insulin or other covered injectable legend drug |
* Note: The member must have been on the medication, under BCBSM coverage, for at least 60 days out of the previous 120 days before being eligible for the 90-day supply.
** Note: We will not pay for drugs obtained from non-network mail order providers, including Internet providers.
Features of your plan
Drug interchange and generic copay waiver |
Certain drugs may not be covered for future prescriptions if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. |
Quantity limits |
Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com |
Rider CI,Contraceptive injections Rider PCD,Prescription contraceptive devices Rider PD-CM,Prescription contraceptive medications |
Adds coverage for contraceptive injections, physician-prescribed contraceptive devices such as diaphragms and IUDs, and “Rx only” oral or injectable contraceptive medications. Note: Riders CI and PCD are part of your medical-surgical coverage, subject to the same deductible and copay, if any, you pay for medical-surgical services. (Rider PCD waives the copay for services provided by a network provider.) Rider PD-CM is part of your prescription drug coverage, subject to the same copay you pay for prescription drugs. |