Covered Services Your Cost In-Network Your Cost Out-of-Network Prescription Drug Bene昀椀ts* At designated retail pharmacies $15 after deductible for Tier 1 $30 after deductible for Tier 1 (up to a 30-day formulary supply for each prescription or re昀椀ll)** 50% coinsurance after 50% coinsurance after deductible for Tier 2 deductible for Tier 2 50% coinsurance after 50% coinsurance after deductible for Tier 3 deductible for Tier 3 Through the designated mail service pharmacy $30 after deductible for Tier 1 Not covered (up to a 90-day formulary supply for each prescription or re昀椀ll)** 50% coinsurance after deductible for Tier 2 50% coinsurance after deductible for Tier 3 * Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs. ** Cost share may be waived or reduced for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. Get the Most from Your Plan: Visit us at bluecrossma.org or call 1-800-782-3675 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Fitness Reimbursement: a program that rewards participation in quali昀椀ed 昀椀tness $150 per calendar year per policy programs or equipment (See your subscriber certi昀椀cate for details.) Weight Loss Reimbursement: a program that rewards participation in a quali昀椀ed $150 per calendar year per policy weight loss program (See your subscriber certi昀椀cate for details.) 24/7 Nurse Line: Speak to a registered nurse, day or night, to get immediate guidance and advice. Call 1-888-247-BLUE (2583). No additional charge. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org. Limitations and Exclusions. These pages summarize the bene昀椀ts of your health care plan. Your subscriber certi昀椀cate and riders de昀椀ne the full terms and conditions in greater detail. Should any questions arise concerning bene昀椀ts, the subscriber certi昀椀cate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your subscriber certi昀椀cate and riders. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 002856696 (5/24) GSP