Your drug benefit

If you have prescription drug coverage, your drug rider explains what medications are covered. It also lists your copayment as a dollar amount or as a percentage of the total prescription cost and indicates when the copayment applies.

Select a drug rider from the left column in the table below to learn more about your drug coverage. Contact Customer Service at 800-662-6667 if you don't know your drug rider or if your drug rider does not appear on this list.

Blue Care Network Required Copayment
Prescription Drug riders Formulary Nonformulary
Drug rider Type Tier 1 Tier 2 Tier 3
$0 Flat $0 $0 $0
$2 Flat $2 $2 $2
$3 Flat $3 $3 $3
$4 Flat $4 $4 $4
$5 Flat $5 $5 $5
$7 Flat $7 $7 $7
$10 Flat $10 $10 $10
$15 Flat $15 $15 $15
$20 Flat $20 $20 $20
$5/$7 2-Tier Closed $5 $7 Not covered
$5/$10 2-Tier Closed $5 $10 Not covered
$5/$11 ($16) 2-Tier Open $5 $11 $11
$5/$11 ($16) 2-Tier Closed $5 $11 Not covered
$5/$15 2-Tier Closed $5 $15 Not covered
$5/$20 2-Tier Closed $5 $20 Not covered
$5/$25 2-Tier Closed $5 $25 Not covered
$5/$30 2-Tier Closed $5 $30 Not covered
$5/$35 2-Tier Closed $5 $35 Not covered
$5/$40 2-Tier Closed $5 $40 Not covered
$5/$50 2-Tier Closed $5 $50 Not covered
$7/$15 2-Tier Closed $7 $15 Not covered
$7/$20 2-Tier Closed $7 $20 Not covered
$10/$15 2-Tier Closed $10 $15 Not covered
$10/$20 2-Tier Closed $10 $20 Not covered
$10/$25 2-Tier Closed $10 $25 Not covered
$10/$30 2-Tier Closed $10 $30 Not covered
$10/$40 2-Tier Closed $10 $40 Not covered
$15/$25 2-Tier Closed $15 $25 Not covered
$15/$30 2-Tier Closed $15 $30 Not covered
$15/$35 2-Tier Closed $15 $35 Not covered
$15/$50 2-Tier Closed $15 $50 Not covered
$20/$60 2-Tier Closed $20 $60 Not covered
$15/40% 2-Tier Closed $15 40% Not covered
$5/$10 (open) 2-Tier Open $5 $10 $10
$5/$15 (open) 2-Tier Open $5 $15 $15
$7/$15 (open) 2-Tier Open $7 $15 $15
$10/$40(open) 2-Tier Open $10 $40 $40
$15/$50(open) 2-Tier Open $15 $50 $50
$3/$12/$25 3-Tier $3 $12 $25
$5/$10/20% 3-Tier $5 $10 20%
$5/$10/$15 3-Tier $5 $10 $15
$5/$10/$20 3-Tier $5 $10 $20
$5/$10/$30 3-Tier $5 $10 $30
$5/$15/$25 3-Tier $5 $15 $25
$5/$20/$30 3-Tier $5 $20 $30
$5/$30/$60 3-Tier $5 $30 $60
$7/$15/$30 3-Tier $7 $15 $30
$7/$20/$35 3-Tier $7 $20 $35
$10/$15/$30 3-Tier $10 $15 $30
$10/$20/$30 3-Tier $10 $20 $30
$10/$25/$40 3-Tier $10 $25 $40
$10/$20/$40 3-Tier $10 $20 $40
$10/$25/$50 3-Tier $10 $25 $50
$10/$30/$60 3-Tier $10 $30 $60
$10/30%/45% 3-Tier $10 30% 45%
$15/$30/$60 3-Tier $15 $30 $60
$15/$50/50% 3-Tier $15 $50 50%
$20/$60/50% 3-Tier $20 $60 50%
25%/35%/45% 3-Tier 25% 35% 45%
20% Percentage 20% 20% 20%
30% Percentage 30% 30% 30%
50% Percentage 50% 50% 50%

page modified 02/25/2009