Page 20 - 2021 Summer Enrollment

Diabetes Equipment and Supplies
Other diabetes equipment, supplies, and prescription drugs not listed below may be covered under these plans. For more information about your prescription drug benefits or for help finding an in-network pharmacy, contact HealthSelect PDP customer care toll-free at (855) 828-9834 (TTY:711). For more information on your medical plan benefits, contact a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 (TTY: 711).
HealthSelect of Texas and HealthSelect Out-of-State
Consumer Directed HealthSelect
Prescription Drug Program (PDP) benefits
Medical plan benefits
Prescription Drug Program (PDP) benefits
Medical plan benefits
Diabetes glucometers
OneTouch Ultra, OneTouch Verio, OneTouch Verio Flex, or OneTouch Verio Reflect Meter* brands of diabetes glucometers are covered at no cost to participants when received through LifeScan's free glucometer program.
For more information on the free glucometer program, call HealthSelect PDP customer care.
Other brands of diabetes glucometers covered under the PDP apply either a Tier 2 or Tier 3 copay when purchased from a PDP in-network pharmacy.
20% coinsurance when purchased from a BCBSTX in-network provider
40% coinsurance after annual out-of-network deductible is met when purchased from
a BCBSTX out-of-network provider
OneTouch Ultra, OneTouch
Verio, OneTouch Verio Flex,
or OneTouch Verio Reflect
Meter* brands of diabetes glucometers are covered at
no cost to participants when received through LifeScan's free glucometer program. For more information on the free glucometer program, call HealthSelect PDP customer care.
Other brands of diabetes glucometers covered under the PDP apply 20% coinsurance after annual in-network deductible is met when purchased from a PDP in-network pharmacy.
20% coinsurance after annual in-network deductible is
met when purchased from a BCBSTX in-network provider
40% coinsurance after annual out-of-network deductible is met when purchased from
a BCBSTX out-of-network provider
Diabetic supplies
OneTouch Ultra, OneTouch Verio, OneTouch Verio Flex,
or OneTouch Verio Reflect* diabetic test strips are covered at no cost to participants when purchased from a PDP in-network pharmacy. Lancets, lancing devices, and syringes are covered at no cost to participants when purchased from a PDP in-network pharmacy.
Other covered diabetic supplies covered under the PDP apply either a Tier 1, Tier 2, or Tier 3 copay when purchased from a PDP in- network pharmacy.
20% coinsurance for in- network and out-of-network covered diabetic supplies. Annual deductible does not apply.
40% coinsurance after annual out-of-network deductible is met when purchased from
a BCBSTX out-of-network provider
20% coinsurance for covered diabetic supplies after annual in-network deductible is met when purchased from a PDP in-network pharmacy.
40% coinsurance after annual out-of-network deductible is met when purchased from a PDP out-of-network pharmacy.
20% coinsurance for in- network and out-of-network covered diabetic supplies. Annual deductible does not apply.
40% coinsurance after annual out-of-network deductible is met when purchased from
a BCBSTX out-of-network provider.
Prescription insulin
In-network pharmacy: Insulin products on the PDP drug list (formulary) are covered at a Tier 1, Tier 2 or Tier 3 copay. The annual prescription drug deductible does not apply
to these products beginning 9/1/21.
Out-of-network pharmacy: Insulin products are covered at a Tier 1, Tier 2 or Tier 3 copay and 40% coinsurance.
Not covered under medical plan benefits
In-network pharmacy: 20% coinsurance for insulin products on the PDP drug list (formulary). The annual prescription drug deductible does not apply to these products beginning 9/1/21.
Out-of-network pharmacy: 40% coinsurance for insulin products after annual out-of- network deductible is met.
Not covered under medical plan benefits
*Benefits and covered brands of glucometers and test strips are subject to change.
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