Does the negotiated rate apply to prescriptions Rx too?
That is, if I have Blue Shield Bronze Plan with no Rx coverage till the $7k OOP Out of Pocket Maximum has been met, do I get the lower negotiated – contracted rates?
Yes, see excerpts from EOC below.
Blue Shield Bronze PPO EOC – Relevant excerpts
Blue Shield Participating Providers
Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, and Alternate Care Services Providers that have a contractual relationship with Blue Shield to provide services to Members of this Plan. Participating Providers are listed in the Participating Provider directory. See below, thus Pharmacies are participating providers.
Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, and Coinsurance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Services, except… Page 2 of EOC
Blue Shield negotiates contracted rates with Participating Pharmacies for Drug. If the Member’s Plan has a Calendar Year Pharmacy Deductible, the Member is responsible for paying the contracted rate for Drugs until the Calendar Year Pharmacy Deductible is met.
The Member must pay the applicable Copayment or Coinsurance for each prescription when the Member obtains it from a Participating Pharmacy. When the Participating Pharmacy’s contracted rate is less than the Member’s Copayment or Coinsurance, the Member only pays the contracted rate. Page 25 of EOC
Learn More===> Page 23 of EOC explains all about Rx benefits
Prior research on our website
Here’s how Medicare under Part D handles it. I grant you, that I don’t understand what CMS is saying here…
Part D Definitions 42 CFR 423.100
The Blue Cross Specimen Policy explains Rx coverage starting on page 120.
Insure Me Kevin.com on Bronze Deductible….