Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

What you’ll pay for prescriptions
Here’s a snapshot of what you’ll pay, depending on the type of drug and where you get it�
Type of drug Network retail
pharmacy
(up to a 30-day supply)
Generic drugs
Preferred brand-name drugs
Nonpreferred brand-name
drugs
Maximum annual out of
pocket for prescriptions
Out-of-network
retail pharmacy
(up to a 30-day supply)
You pay a $5 copay� You pay a $5 copay
+
(full cost – CVS Caremark
discounted amount)�
You pay 30% of covered
charges with $60 maximum
per prescription�
You pay 40% of covered
charges with $90 maximum
per prescription�
The following Plan provisions also apply to all
prescription drug claims processing:
• It’s standard practice in most pharmacies (and, in some
states, a legal requirement) to substitute the generic
equivalent for brand-name drugs whenever possible�
• If you purchase a brand-name drug when a generic
equivalent is available, you will pay the generic copay,
plus the diference in cost between the brand-name
drug and the generic drug� Any diference in cost
between the brand and generic is not applied to any
maximum per prescription amount listed above� At
mail order, the diference in cost that you pay is not
applied to the annual out-of-pocket maximum� If your
doctor requests the brand-name drug (i�e�, because it
is medically necessary), you will pay the nonpreferred
brand-name drug coinsurance amount�
• There are no exceptions to any of the copay or
coinsurance amounts listed above, even with a
physician’s request� For example, if the drugs on the
preferred list are not appropriate for you, and you
choose a drug that’s not on the list, you will still have
to pay the higher copay or coinsurance amount�
48
You pay 30% of covered
charges with $60 maximum
per prescription
+
(full cost – CVS Caremark
discounted amount)�
You pay 40% of covered
charges with $90 maximum
per prescription
+
(full cost – CVS Caremark
discounted amount)�
CVS Caremark
Mail Service
(up to a 90-day supply)
You pay a $10 copay�
You pay 30% of covered
charges with $90 maximum
per prescription�
You pay 40% of covered
charges with $140 maximum
per prescription�
Not applicable Not applicable $1,000 per individual and
$2,000 per family — mail only
• Prescriptions for certain specialty drugs (typically
self-injectables) cannot be flled at retail pharmacies�
For more information, see the “CVS Caremark
Specialty Pharmacy” section on page 49�
• CVS Caremark Mail Service is the only approved
mail-order provider� Any drugs ordered by mail from
another provider will not be covered�
• Certain prescriptions have quantity limits� Contact
CVS Caremark if you have questions about possible
quantity limits for your prescriptions�
• You’ll need to get prior approval from CVS
Caremark for certain prescriptions� For more
information, see the “Some prescriptions may require
prior authorization” section on page 49�
Anthem Blue Cross Blue Shield PPO Plan