January 2022 Prescription Drug Options
Large Groups (101 and above)
You can offer your clients prescription drug options with a range of copayments and rates. These options – more than 85 in all – cover drugs and supplies in the Blue Shield Drug Formulary, including drugs and devices, contraceptives, diabetic supplies and more. You'll have flexibility when offering affordable choices that enhance your clients' medical plan.
Select a drug coverage plan to accompany the health plan your client is interested in. The information below is effective January 1, 2022 for groups with 101 or more eligible employees.
Prescription drug options
2022 Rx Riders for HMO and POS plans
| Basic Rx Riders for HMO and POS plans | Download and size |
|---|---|
| Basic Rx $10/15 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/15 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/20 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/20 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/20 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/25 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $10/25 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/25 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/25 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/25 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/30 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/30 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Basic Rx $15/30 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx Riders for HMO and POS plans | Download and size |
|---|---|
| Enhanced Rx $5/10/25 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $5/10/25 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/15/30 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/15/30 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) MB) |
| Enhanced Rx $10/20/35 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/20/35 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/20/35 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/35 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Premier Rx Riders for HMO and POS plans | Download |
|---|---|
| Premier Rx $0/10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Premier Rx $0/10/25/40 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Premier Rx $0/10/25/40 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| RX Spectrums Riders for HMO and POS plans | Download |
|---|---|
| Rx Spectrum $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
2022 Rx Riders for PPO/EPO plans
| Enhanced Rx Riders for PPO/EPO plans | Download and size |
|---|---|
| Enhanced Rx $5/10/25 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $5/10/25 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/15/30 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/15/30 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/15/30 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/20/35 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/20/35 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/20/35 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/25/40 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $10/30/50 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/45 with $250 Pharmacy Deductible | English (PDF, 1MB) Spanish (PDF, 1.7MB) |
| Enhanced Rx $15/30/50% $100 max with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $15/40/70 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx $20/40/60 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/20/35 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/20/35 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/20/35 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/25/40 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $10/30/50 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/30/45 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $15/40/70 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Enhanced Rx - Value Formulary $20/40/60 with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum Riders for PPO plans | Download and size |
|---|---|
| Rx Spectrum $0/10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $10/25/40 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $15/30/45 with $0 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $15/30/45 with $150 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
| Rx Spectrum $15/30/50% $100 max with $250 Pharmacy Deductible | English (PDF, 1 MB) Spanish (PDF, 1.7 MB) |
2022 Rx Riders for Active Choice plans
| Enhanced Rx Riders for Active Choice plans | Download and size |
|---|---|
| Enhanced Rx $10/25/40 with $0 Pharmacy Deductible | English (PDF, 749 KB) Spanish (PDF, 779 KB) |
| Enhanced Rx $10/25/40 with $150 Pharmacy Deductible | English (PDF, 750 KB) Spanish (PDF, 779 KB) |
| Enhanced Rx $10/25/40 with $250 Pharmacy Deductible | English (PDF, 751 KB) Spanish (PDF, 779 KB) |
| Enhanced Rx $15/30/45 with $0 Pharmacy Deductible | English (PDF, 749 KB) Spanish (PDF, 778 KB) |
| Enhanced Rx $15/30/45 with $150 Pharmacy Deductible | English (PDF, 749 KB) Spanish (PDF, 778 KB) |
| Enhanced Rx $15/30/45 with $250 Pharmacy Deductible | English (PDF, 749 KB) Spanish (PDF, 778 KB) |
