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SMALL EMPLOYER MEMBER PAYMENT SUMMARY (MPS) …
Jan 01, 2021 · PRESCRIPTION DRUGS 3 Prescription Drug List (formulary) Prescription Drug Deductible - Per Person Out-of-Pocket Maximum Prescription Drugs – Up to 30-day supply for covered medications Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Maintenance Drugs – 90-day supply (Mail-Order, Retail90 ®) Tier 1 Tier 2 Tier 3 Tier 4 Generic Substitution Required ...
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INDIVIDUAL PAYMENT SUMMARY
selecthealth.orgJan 01, 2021 · PREVENTIVE CARE AS OUTLINED BY THE ACA 2 IN-NETWORK OUT-OF-NETWORK Office Visits (PCP/SCP)1 Covered 100% 50% after Deductible Adult and Pediatric Immunizations Covered 100% 50% after Deductible Diagnostic Tests: Minor Covered 100% 50% after Deductible Other Preventive Services Covered 100% 50% after Deductible VISION …
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2022 Formulary (List of Covered Drugs)
www.bcbstx.comBlue Cross Medicare Advantage Classic (PPO)SM 2022 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File ID: 00022273, Version 08 This formulary was updated on 01/13/2022. For more recent information or other questions, please …
Horizon Blue Cross Blue Shield of New Jersey Classic Drug ...
www.myprime.comThe drug list is an open formulary. This means all FDA approved medicines are included. However, certain drug classes are excluded from coverage (not covered) including investigational and cosmetic drugs (such as Propecia for hair growth). Coverage, copayment, and additional restrictions and exclusions may vary depending on your