Pharmacy Program Summary of Benefits
Formulary 3 ■ 5-Tier ■ $0 Deductible ■ $10/25/45 ■ Specialty 50%/50%
Plan Feature
Amount You Pay
Description
Your benefit does not have a deductible.
None
Individual Deductible
Your benefit does not have a family deductible.
None
Family Deductible
See medical summary of benefits for annual out‑of‑pocket amount
If you reach your out‑of‑pocket maximum, CareFirst or CareFirst BlueChoice will pay 100% of the applicable allowed benefit for most covered services for the remainder of the year. All deductibles, copays, coinsurance and other eligible out‑of‑pocket costs count toward your out‑of‑pocket maximum, except balance billed amounts. A preventive drug is a prescribed medication or item on CareFirst’s Preventive Drug List.* Diabetic supplies include needles, lancets, test strips and alcohol swabs.
Out-of-Pocket Maximum
Preventive Drugs (up to a 34‑day supply) Oral Chemotherapy Drugs and Diabetic Supplies (up to a 34‑day supply) Generic Drugs (Tier 1) (up to a 34‑day supply) Preferred Brand Drugs (Tier 2) (up to a 34‑day supply) Non-preferred Brand Drugs (Tier 3) (up to a 34‑day supply) Preferred Specialty Drugs (Tier 4) (up to a 34‑day supply) Non-preferred Specialty Drugs (Tier 5) (up to a 34‑day supply)
$0
$0
Generic drugs are covered at this copay level.
$10
All preferred brand drugs are covered at this copay level.
$25
All non‑preferred brand drugs on this copay level are not on the Preferred Drug List.* Discuss using alternatives with your physician or pharmacist.
$45
50% up to a $100 maximum You pay 50% coinsurance up to a maximum of $100 for all preferred specialty drugs. Benefits for covered Specialty drugs are available when purchased by mail order. 50% up to a $150 maximum You pay 50% coinsurance up to a maximum of $150 for all non‑ preferred specialty drugs. Benefits for covered Specialty drugs are available when purchased by mail order.
Generic: $20 Preferred Brand: $50
Maintenance Drugs (up to a 90‑day supply)
Maintenance generic, preferred brand and non‑preferred brand drugs up to a 90‑day supply are available for twice the copay through Mail Service Pharmacy or a retail pharmacy. Maintenance preferred and non‑preferred specialty drugs up to a 90‑day supply you pay 50% coinsurance up to a maximum copay. Benefits for covered Specialty drugs are available when purchased by mail order.
Non‑preferred Brand: $90 Preferred Specialty: 50% up to a $200 maximum Non‑preferred Specialty: 50% up to a $300 maximum
If a provider prescribes a non‑preferred brand drug when a generic is available, you will pay the non‑preferred brand copay or coinsurance PLUS the cost difference between the generic and brand drug up to the cost of the prescription. If a generic version is not available, you will only pay the copay or coinsurance. Also, if your prescription is written for a brand‑name drug and DAW (dispense as written) is noted by your doctor, you will only pay the copay or coinsurance.
Restricted Generic Substitution
Visit carefirst.com/rx for the most up-to-date drug lists, including the prescription guidelines. Prescription guidelines indicate drugs that require your doctor to obtain prior authorization from CareFirst before they can be filled and drugs that can be filled in limited quantities.
This plan summary is for comparison purposes only and does not create rights not given through the benefit plan. Policy Form Numbers: VA/CFBC/RX3 (R. 1/18) • VA/CF/RX3 (R. 1/18)
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