Valley Baptist Health Plan Preferred Drug List

Preferred Drug List



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Your Valley Health Plans includes a prescription drug benefit.

Your prescription drug benefit includes generic drugs and name brand medications that are used by physicians as they prescribe medicines for their patients. The Preferred Drug List is overseen by a panel of physicians and pharmacists, who evaluate the various drugs available to treat specific conditions.

Medications that do not appear on the Preferred Drug List are referred to as Non-Preferred Drugs. When used to treat a covered medical condition, Non-Preferred Drugs are available at the 3rd tier retail copayments of $40 or $55, and $120 mail order copayment.

Some medications, whether listed on the Preferred Drug List or not, may require Prior Authorization in order to be a covered benefit. Your specific prescription benefit plan design may not cover certain categories of drugs, regardless of their appearance in this list.

Prescription: Deductible per person per plan year $50

Prescription Drugs	$50 Plan Year Deductible
Participating Retail Pharmacy	Tier 1 Primarily generic drugs	Tier 2 Mostly preferred brand name drugs	Tier 3 Non-preferred brand name drugs and other preferred brand name drugs
Up to a 30-day supply per prescription or refill of Non-Maintenance medication	$10	$25	$40
Up to a 30-day supply prescription or refill of Maintenance medication	$15	$35	$55
Up to a 30-day supply of insulin for one copayment	$10	$25	$40
The supply of necessary disposable syringes for the insulin supply for one copayment	$10	$25	$40
This benefit also includes diabetic supplies as specified in Art. 21.53G,Tex. Ins.code. Up to a 30-day supply for a 20% copayment	0	0	20%
Infertility drugs are paid at 50% copayment	0	0	50%

If a Brand Name medication is dispensed when a generic is available, member will be responsible for the generic copayment plus the cost difference between the generic and the brand name medication

Prescription Drugs	$50 Plan Year Deductible
Mail Order Pharmacy	Tier 1 Primarily generic drugs	Tier 2 Mostly preferred brand name drugs	Tier 3 Non-preferred brand name drugs and other preferred brand name drugs
Up to a 90-day supply per prescription or refill of Non-Maintenance medication	$30	$75	$120
Up to a 90-day supply prescription or refill of Maintenance medication	$30	$75	$120
Up to a 90-day supply of insulin for one copayment	$30	$75	$120
The supply of necessary disposable syringes for the insulin supply for one copayment	$30	$75	$120
This benefit also includes diabetic supplies as specified in Art. 21.53G,Tex. Ins.code. Up to a 30-day supply for a 20% copayment	0	0	20%
Infertility drugs are paid at 50% copayment	0	0	50%

If a Brand Name medication is dispensed when a generic is available, member will be responsible for the generic copayment plus the cost difference between the generic and the brand name medication

Your Valley Health Plans includes a prescription drug benefit.

Your prescription drug benefit includes Primarily generic drugs, Mostly Preferred brand name drugs, and Non-preferred brand name drugs and other preferred brand name drugs.

Medications that do not appear on the mostly preferred brand name drug list are referred to as Non-preferred brand name drugs and other preferred brand name drugs. When used to treat a covered medical condition, Non-preferred drugs are available at the 3rd tier retail copayments of $40 or $55, and $120 mail order copayment.

Some medications, whether listed on the Preferred Drug List or not, may require Authorization in order to be a covered benefit.

Prescription: Deductible per person per plan year $50

For specific information regarding your prescription coverage, please consult a Valley Health Plans Customer Services Representative at 800-829-6440 or refer to your Evidence of Coverage.

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