Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by...
Retail Prescriptions. Contraceptive Drugs and Devices2 $0 per prescription Not covered Formulary Generic Drugs $15 per prescription Not covered Formulary Brand Name Drugs $30 per prescription Not covered Non-Formulary Brand Name Drugs Not covered Not covered Mail Service Prescriptions Contraceptive Drugs and Devices2 $0 per prescription Not covered Formulary Generic Drugs $30 per prescription Not covered Formulary Brand Name Drugs $60 per prescription Not covered Non-Formulary Brand Name Drugs Not covered Not covered Specialty Pharmacies Specialty Drugs 20% of the Blue Shield contracted rate up to a maxi- mum of $100 per prescription Not covered 1 Drugs obtained at a Non-Participating Pharmacy are not covered, unless Medically Necessary for a covered emergency, including Drugs for emergency contraception. See the Obtaining Outpatient Prescription Drugs at a Non-Participating Pharmacy section for details. 2 If a Brand Name contraceptive Drug is requested when a Generic Drug equivalent is available, the Member will be respon- sible for paying the difference between the cost for the Brand Name contraceptive Drug and its Generic Drug equivalent. In addition, select contraceptives may require prior authorization to be covered without a Copayment. This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal govern- ment for Medicare Part D (also called creditable coverage). Because this plan’s prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.
Retail Prescriptions. For each prescription dispensed by a CarePlus Participating Pharmacy to an Enrollee, CarePlus agrees to pay GO2Pharmacy.com the reimbursement rate CarePlus has xxxxxxxxxx xxxh CarePlus participating pharmacies, which is the lesser of:
