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Prescription Drug Benefits SummaryBENEFIT TRS-ACTIVECAREPRIMARY*Drug Deductible(per person, per plan year)Integrated with medicalMOOP Integrated with medicalShort-Term Supply (up to a 31-day supply)Generic $15 copay, $0 copay for certain genericsPreferred Brand 30% coinsurance after deductibleNon-Preferred Brand 50% coinsurance after deductibleInsulin Out-of-Pocket Cost $25 copayLong-Term Supply (61- to 90-day supply)Generic $45 copay, $0 copay for certain genericsPreferred Brand 30% coinsurance after deductibleNon-Preferred Brand 50% coinsurance after deductibleFormulary Insulin Out-of-Pocket $75 copaySpecialty Medications through Accredo (up to a 31-day supply)Specialty Medications 30% coinsurance after deductibleSpecialty Medications through SaveOnSP copay assistance programSpecialty Medications on the SaveOnSP Drug List $0 copayDiabetic Meter and SuppliesMETER AND SUPPLIESTRS-ACTIVECARE PRIMARY*Preferred Brand Blood Glucose Meter $0Short-Term Retail Supplies$0 for select needles, lancets and syringes.90-Day Supply at Express Scripts Mail or In-network Participating Retail Pharmacy$0 for select needles, lancets and syringes, regardless of brand. To get test strips at no added cost, you must use the preferred brand.Coinsurance applies after deductible.*including TRS-ActiveCare Primary x Arlington and TRS-ActiveCare Primary x Region 4 plansSaveOnSP is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide pharmacy benefit management for members with coverage through BCBSTX.Prescription Answers and Information Online 24/7 Once you enroll in TRS-ActiveCare, register with Express Scripts at www.express-scripts.com/trsactivecare. Log in anytime to fill or refill long-term prescriptions, find drug coverage and price information, talk with a registered pharmacist, view your prescription history, download the app and much more.28 www.bcbstx.com/trsactivecare