Understand Your Pharmacy Benefits

Based on your health plan, your prescription drug costs may depend on if you’ve met your in-network deductible.  

First, you’ll pay your prescription’s full cost upfront until you meet your in-network deductible. After you’ve met your in-network deductible, you’ll pay an out-of-pocket cost of a copay or coinsurance for covered prescription drugs. Your out-of-pocket costs are based on the drug’s payment tier and your plan benefits. 

See how this all works when you get a prescription:

  • View Transcript

    At Blue Cross and Blue Shield of Texas (BCBSTX) we know that pharmacy benefits can raise many questions, like how the cost of your prescription applies to your in-network deductible and in-network out of pocket maximum. Let’s take a look at an example.

    Meet Sophia. She recently got diagnosed with asthma and her doctor prescribed her a medication.

    Sophia’s BCBSTX health plan has a $3,500 in-network deductible and $6,000, in-network out of pocket maximum.

    As a member, Sophia will pay $181* for her inhaler medication for a 30-day supply. This is her in-network pharmacy cost negotiated by Blue Cross and Blue Shield, so she pays a lower out of pocket amount.

    This prescription payment of $181 will count toward meeting her in-network deductible of $3,500. Other covered in-network medical expenses also go towards her in-network deductible, like in-network doctor visits.

    Once she reaches her $3,500 in-network deductible, Sophia will pay for her medication based on a 6-tier prescription drug list. Depending on which tier her drug falls, Sophia will pay a set amount (copay) or percentage (coinsurance), based on her benefits. In general, the lower the drug tier, the lower the out-of-pocket costs.

    To find out which drug tier her prescription falls into, Sophia can search the drug list at FindaMedicationTX.com. With her plan, Sofia’s inhaler prescription falls under tier 3 or “Preferred Brand," meaning she is responsible for paying only 30% of the $181 medication. Which is $54.30.

    Once Sofia’s in network pharmacy and in-network medical payments have reached her out of pocket maximum of $6,000, 100% of her medication may be covered by Blue Cross and Blue Shield when she uses an in-network pharmacy.

    Of course, everyone’s situation is unique, and you may have more questions about how your plan works for you.

    For additional questions about your pharmacy benefits, please visit MyBlueRxTX.com or call the number on the back of your member ID card.

    *Out of pocket costs can vary depending on a plan in-network deductible, benefits and additional factors. Out of pocket costs subject to change.

Help With Lowering Your Costs 

You may keep your prescription drug costs down if you:

  • Fill your prescriptions at an in-network pharmacy
  • Ask your doctor if a covered alternative is an option
  • Get up to a 90-day supply of covered drugs used regularly1

See how to review prescription drug lists and costs online.

Remember, pharmacy selections and your care are always between you and your doctor.

Ask your doctor if you have questions or concerns about your medications.

How Prescription Drug Tiers Work 

Your health plan’s prescription drug list has many levels of coverage, called member payment tiers.  

Your pharmacy benefit has up to 6 tiers. Each tier has its own cost. Most often, the lower the tier, the lower your out-of-pocket costs will be for the drug.  

When you get a prescription, you can look up the drug tier on your drug list.

Understanding and Using Your Drug List

After you meet your annual in-network deductible, you’ll pay for your prescription based on its tier on the drug list.  

When you look up your prescription drugs, seeing the drug tier lets you know if you’ll pay lower or higher out-of-pocket costs. It can also show you if your prescription drugs have any additional requirements.

The example from the drug list shows a drug that:

  • Is in tier 5 (preferred specialty drug)
  • Requires prior authorization
  • Has a dispensing limit

Prescription Drug Lists and Costs

Find your medication and learn more about viewing drug costs online:

2022 Individual and Family Health Plans

2022 Drug List

2022 $0 HDHP-HSA Preventive Drug List (This applies for Blue Advantage Plus BronzeSM 501 plan) 

  • View Transcript

    At Blue Cross and Blue Shield of Texas (BCBSTX), we know pharmacy benefits and costs can be confusing.  We’re here to help make it a little bit easier for you to understand your drug coverage and cost. Let’s look at an example.

    Meet Sofia. She was diagnosed with asthma and her doctor prescribed a medication to treat it.

    With her BCBSTX health care plan, she wants to know if her medication is covered and what her total prescription cost may be.

    Luckily for Sofia, she can find these answers through her online member account. Under the “Quick Links”, Sofia selects the Prescription Drugs link to access MyPrime.com, the member website of BCBSTX's pharmacy benefit manager.

    Once on MyPrime.com, Sofia can select “Find medicines” to search for her prescription drug. From there, she can see if her drug is covered and how much it may cost.

    For additional savings, Sofia can choose to “see all pricing options” to view generic options and in-network and preferred pharmacy costs. If her drug is not covered, Sofia can speak with her doctor to discuss her options.

    Keep in mind, drug costs are unique to every plan and prescription. They can also vary depending on your plan’s in network deductible, and benefits. To find out how you can save on your covered drugs, visit MyBlueRxTX.com. 


Learn About Additional Requirements

Some drugs listed in the drug list may have additional requirements. This means there may be extra steps to take before getting your prescription filled.

Prior Authorization

In some cases, your doctor will need to send us a pre-approval request before your prescription drug may be covered.

Step Therapy

You may need to first try a more cost-effective drug before some other drug may be covered.

Dispensing Limits

You may only be able to get a certain amount of your drug at one time. Review drug dispensing limits.

Specialty Pharmacy Program

You may need to get a specialty drug at an in-network specialty pharmacy.  Some drugs may be filled in a smaller amount (split fill), letting you try them at a prorated cost first.  View specialty pharmacy program details.

More Suggestions For You

Scheduling Your Annual Exam


Understand Health Care Plans


Useful Tools and Resources


1 Not all prescriptions can be filled in a 90-day supply and may need to be filled at select retail pharmacies or via home delivery. Based on your plan benefits, you may not save on your out-of-pocket costs but will spend less time going to the pharmacy.