BASIC HMO (BRONZE HMO) & BASIC PPO (BRONZE PPO)

• $6,650 Individual/$13,300 Family In-Network Deductible
• Covered medications paid by insured until plan deductible is satisfied.

PLUS HMO (SILVER HMO) 

• $100 annual prescription deductible
  • $15 Generic Copay
  • $35 Brand Copay
  • $65 Brand Non-Formulary Copay

PREMIER PPO (SILVER PPO) 

• $100 annual prescription deductible
  • $15 Generic Copay
  • $35 Brand Copay
  • $65 Brand Non-Formulary Copay

DETAILS TO KNOW

• Walgreen’s pharmacy locations are out of network for Lubbock ISD prescription coverage.
• United Pharmacy $0 Copay Generics prescribed through $0 Copay Clinic providers do not apply to CVS prescription coverage.
• A separate CVS Caremark prescription card is used at pharmacy locations. DO NOT use your BCBS medical plan card for prescription coverage.
• One CVS prescription card per family is mailed to the employee’s home address.
• Monthly maintenance medications are filled for 90-days with CVS mail order/CVS retail.