Missouri Plan Benefits
Learn more about the Blue Preferred POS High Option
Let’s break down some details of the High Option, Blue Preferred Plus Point-of-Service (POS) plan.
- You can visit network or non-network providers
- Know before you go: Those non-network providers are going to cost a little more out-of-pocket for you
- When you see network providers, there’s no deductible . . . you’ll have lower out-of-pocket, too
Pharmacy Benefits for Blue Preferred® High Option
Prescription Drug Copays for 2022
Level 1 |
||||
|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $5 copay | $60.00 | $10 copay | $40.00 |
| Tier 2 | $60 copay | $720.00 | $150 copay | $600.00 |
| Tier 3 | $80 copay | $960.00 | $200 copay | $800.00 |
| Tier 4 | 25% of our allowance ($250 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
Level 2 |
||||
|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $15 copay | $180.00 | N/A | N/A |
| Tier 2 | $70 copay | $840.00 | N/A | N/A |
| Tier 3 | $90 copay | $1,080.00 | N/A | N/A |
| Tier 4 | 25% of our allowance ($250 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
Level 1
$5 copay
$60.00
$10 copay
$40.00
$60 copay
$720.00
$150 copay
$600.00
$80 copay
$960.00
$200 copay
$800.00
25% of our allowance
($250 maximum per prescription)
–
90-day supply is not available
90-day supply is not available
Level 2
$15 copay
$180.00
N/A
N/A
$70 copay
$840.00
N/A
N/A
$90 copay
$1,080.00
N/A
N/A
25% of our allowance
($250 maximum per prescription)
–
90-day supply is not available
90-day supply is not available
On the next page, choose Essentials Tier-4
*Please note that pricing information is based on filling prescriptions at a Level 1 pharmacy. Add $10 to your copay if you’re having your prescriptions filled at a Level 2 pharmacy.
Learn more about the Blue Preferred HMO Standard Option
Let’s break down some details for the Standard Option, Blue Preferred Health Maintenance Organization (HMO) plan.
- You have to stay in network with this plan
- No referrals required for network providers
- No annual deductible
Pharmacy Benefits for Blue Preferred® Standard Option
Prescription Drug Copays for 2022
Level 1 |
||||
|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $10 copay | $120.00 | $20 copay | $80.00 |
| Tier 2 | $70 copay | $840.00 | $175 copay | $700.00 |
| Tier 3 | $90 copay | $1,080.00 | $225 copay | $900.00 |
| Tier 4 | 25% of our allowance ($250 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
Level 2 |
||||
|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $20 copay | $240.00 | N/A | N/A |
| Tier 2 | $80 copay | $960.00 | N/A | N/A |
| Tier 3 | $100 copay | $1,200.00 | N/A | N/A |
| Tier 4 | 25% of our allowance ($250 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
On the next page, choose Essentials Tier-4
*Please note that pricing information is based on filling prescriptions at a Level 1 pharmacy. Add $10 to your copay if you’re having your prescriptions filled at a Level 2 pharmacy.
