January 2022 Prescription Drug Options

Large Groups (101 and above)

 

You can offer your clients prescription drug options with a range of copayments and rates. These options – more than 85 in all – cover drugs and supplies in the Blue Shield Drug Formulary, including drugs and devices, contraceptives, diabetic supplies and more. You'll have flexibility when offering affordable choices that enhance your clients' medical plan.

Select a drug coverage plan to accompany the health plan your client is interested in. The information below is effective January 1, 2022, for groups with 101 or more eligible employees.

Prescription drug options

2022 Rx Riders for HMO and POS plans

Basic Rx Riders for HMO and POS plans Download and size
Basic Rx $10/15 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/15 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/20 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/20 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/20 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/25 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $10/25 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/25 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/25 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/25 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/30 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/30 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Basic Rx $15/30 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx Riders for HMO and POS plans Download and size
Enhanced Rx $5/10/25 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $5/10/25 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/15/30 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/15/30 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
MB)
Enhanced Rx $10/20/35 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/20/35 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/20/35 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/35 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Premier Rx Riders for HMO and POS plans Download
Premier Rx $0/10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Premier Rx $0/10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Premier Rx $0/10/25/40 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
RX Spectrums Riders for HMO and POS plans Download
Rx Spectrum $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

2022 Rx Riders for PPO/EPO plans

Enhanced Rx Riders for PPO/EPO plans Download and size
Enhanced Rx $5/10/25 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $5/10/25 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/15/30 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/15/30 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/15/30 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/20/35 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/20/35 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/20/35 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/25/40 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $10/30/50 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/45 with $250 Pharmacy Deductible English (PDF, 1MB)
Spanish (PDF, 1.7MB)
Enhanced Rx $15/30/50% $100 max with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/30/50% $100 max with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $15/40/70 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx $20/40/60 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/20/35 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/20/35 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/20/35 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/25/40 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $10/30/50 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/30/45 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $15/40/70 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Enhanced Rx - Value Formulary $20/40/60 with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Premier Rx Riders for PPO/EPO plans Download
Premier Rx $0/10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Premier Rx $0/10/25/40 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum Riders for PPO plans Download and size
Rx Spectrum $0/10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $10/25/40 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $15/30/45 with $0 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $15/30/45 with $150 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)
Rx Spectrum $15/30/50% $100 max with $250 Pharmacy Deductible English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

2022 Rx Riders for Active Choice plans

Enhanced Rx Riders for Active Choice plans Download and size
Enhanced Rx $10/25/40 with $0 Pharmacy Deductible English (PDF, 749 KB)
Spanish (PDF, 779 KB)
Enhanced Rx $10/25/40 with $150 Pharmacy Deductible English (PDF, 750 KB)
Spanish (PDF, 779 KB)
Enhanced Rx $10/25/40 with $250 Pharmacy Deductible English (PDF, 751 KB)
Spanish (PDF, 779 KB)
Enhanced Rx $15/30/45 with $0 Pharmacy Deductible English (PDF, 749 KB)
Spanish (PDF, 778 KB)
Enhanced Rx $15/30/45 with $150 Pharmacy Deductible English (PDF, 749 KB)
Spanish (PDF, 778 KB)
Enhanced Rx $15/30/45 with $250 Pharmacy Deductible English (PDF, 749 KB)
Spanish (PDF, 778 KB)

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