For prescriptions purchased at an in-network pharmacy, copayment amounts are $10, $30, or $50 based on the brand/formulary of the drug. If an out-of-network pharmacy is used, pharmacy prescription drug benefits are paid at 75%. 

 

 

For prescriptions purchased through the mail order program, copayment amounts are $20, $60, or $100 based on the brand/formulary of the drug. This benefit provides up to a 90-day supply of maintenance drugs used on a continuous basis for treatment of chronic health conditions. Please use the form below:
BlueCross BlueShield Mail Order Prescription Form

For questions regarding your prescription plan, you can contact BlueCross BlueShield at 800-423-1973 or visit https://www.myprime.com/en.html .