15 / 68
15
Medical- Blue Shield Rx
Blue Shield PPO 100% Plan A $20 copay
Walk-In (Retail)
Mail Order
In-Network
Costco
Costco
Navitus
Supply Limit
30 days
30 days
90 days
90 days
30 days
Generic
$5 copay
Free
Free
Free
Brand
$20 copay
$20 copay
$50 copay
$50 copay
Specialty
$20 copay
Out-of-Pocket
Maximum
$1,500 individual / $2,500 family
Blue Shield PPO 80% Plan K $30 copay
Walk-In (Retail)
Mail Order
In-Network
Costco
Costco
Navitus
Supply Limit
30 days
30 days
90 days
90 days
30 days
Generic
$9 copay
Free
Free
Free
Brand
$35 copay
$35 copay
$90 copay
$90 copay
Specialty
$35 copay
Out-of-Pocket
Maximum
$2,500 individual / $3,500 family
WHY USE MAIL ORDER?
•
Save money & time: You’ll get as much as 90-day supply of your monthly prescription which saves you
fewer refills and lower out of pocket costs.
•
Enjoy the convenience: Your medications come right to your doorstep with standard shipping at no cost
to you.
The information in this booklet is a general outline of the benefits offered under College of Marin benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.