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17
Medical- Blue Shield Rx
Blue Shield PPO Two Tier Bronze
(
subject to deductible)
In-Network
Out-of-Network
1
Pharmacy
Generic
$9 copay
$9 copay
Brand
$35 copay
$35 copay
Non-formulary brand
$35 copay
$35 copay
Supply Limit
30 days
30 days
Mail Order
Generic
$18 copay
Not Covered
Brand
$90 copay
Not Covered
Non-formulary brand
$90 copay
Not Covered
Supply Limit
90 days
1
To obtain prescription drugs at a non-participating pharmacy, the member must first pay all charges for the prescription and submit a
completed Prescription Drug Claim Form for reimbursement. The member will be reimbursed the price paid for the drug less any applicable
deductible, copayment or coinsurance (Generic, Formulary Brand, or Non-Formulary Brand) and any applicable out of network charge.
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.