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Drug Benefits

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    What is a prescription co-payment and/or co-insurance?

    A prescription co-payment and/or co-insurance, is the portion of the covered drug that you are required to pay each time you fill a prescription, Blue Shield pays the remainder. Usually the co-payment is a flat dollar amount, and the co-insurance is a percentage amount of the drug cost. There are usually different co-payments for generic, brand formulary, and brand non-formulary drugs (if your plan has a benefit for non-formulary drugs). Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for your specific copayment information.
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    My drug is a non-formulary drug. Is it covered?

    Some plans have a benefit to include coverage of non-formulary drugs. Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) to find out if your plan covers these drugs. You may have coverage subject to higher co-payments and/or co-payment percentages. If your plan does not cover non-formulary drugs and you have tried the formulary alternatives or changing to a formulary drug would be inappropriate, your physician may contact Pharmacy Services to request prior authorization.  You may also request prior authorization by contacting Blue Shield Member Services at (800) 443-5005, or TTY at (800) 241-1823.
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    How can I pay a lower copayment on prescriptions?

    When a physician prescribes a brand-name medication, you should ask if a generic drug is available to treat your condition. If a generic drug is not available to treat your condition, your copayments will be lower if your physician selects a formulary over a non-formulary brand name drug. return to top

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    What is a pharmacy benefit deductible?

    Some plans may have a pharmacy benefit deductible, which is the set dollar amount which must be paid by you for each calendar year for covered prescriptions before your co-payments, and/or co-insurances apply. return to top

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    How do I know if I have a prescription drug benefit?

    Check your Blue Shield of California ID card, you will see a "Yes" under “RX” if you have a prescription drug benefit.  You may also call Member Services to find out if you have a prescription drug benefit.
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